ARDS is an unexpected, catastrophic pulmonary complication
occurring in a person with no previous pulmonary problems. The mortality rate is high (5!" #n ARDS, a common laboratory $inding is lowered %&'. (owever, these clients are not very responsive to high concentrations o$ oxygen. Thin) about the physiology o$ the lungs by remembering %**%+ %ositive *nd *xpiratory %ressure is the instillation and maintenance o$ small amounts o$ air into the alveolar sacs to prevent them $rom collapsing each time the client exhales. The amount o$ pressure can be set with the ventilator and is usually around 5 to , cm o$ water. Suction only when secretions are present. -e$ore drawing arterial blood gases $rom the radial artery, per$orm the Allen test to assess collateral circulation. .a)e the client/s hand blanch by obliterating both the radial and ulnar pulses. Then release the pressure over the ulnar artery only. #$ $low through the ulnar artery is good, $lushing will be seen immediately. The Allen test is then positive, and the radial artery can be used $or puncture. #$ the Allen test is negative, repeat on the other arm. #$ this test is also negative, see) another site $or arterial puncture. The Allen test ensures collateral circulation to the hand i$ thrombosis o$ the radial artery should $ollow the puncture. #$ the client does not have &' to his0her brain, the rest o$ the in1uries do not matter because death will occur. (owever, they must be removed $rom any source o$ imminent danger, such as a $ire. %2"' 345 or %&' 56 on 5! &' signi$ies respiratory $ailure. A child in severe distress should be on ,! &'. *arly signs o$ shoc) are agitation and restlessness resulting $rom cerebral hypoxia. #$ cardiogenic shoc) exists with the presence o$ pulmonary edema, i.e., $rom pump $ailure, position client to R*D72* venous return ((#8( 9&:;*R/s with legs down" in order to decrease venous return $urther to the le$t ventricle. Severe shoc) leads to widespread cellular in1ury and impairs the integrity o$ the capillary membranes. 9luid and osmotic proteins seep into the extra vascular spaces, $urther reducing cardiac output. A vicious cycle o$ decreased per$usion to A;; cellular level activities ensues. All organs are damaged, and i$ per$usion problems exist, the damage can be permanent. All vasopressors0vasodilator drugs are potent and dangerous and re<uire weaning on and o$$. Do not change in$usion rates simultaneously. A client is brought into the hospital su$$ering shoc) symptoms as a result o$ a bee sting. :hat is the $irst priority= .aintaining an open airway (the allergic reaction damages the lining o$ the airways causing edema". Also, )eep the client warm without constricting clothing> )eep legs elevated (not Trendelenburg because the weight o$ the lower organs restricts breathing". *pinephrine+ ,+,, .' to .5ml sub< $or mild *pinephrine+ ,+,,, or 5ml #? $or severe ?olume expanding $luids are usually given to clients in shoc). (owever, i$ the shoc) is cardiogenic, pulmonary edema may result. Drugs o$ choice $or shoc) - Digitalis preparations+ #ncrease the contractility o$ the heart muscle - ?asoconstrictors (;evophed, Dopamine"+ 8enerali@ed vasonconstriction to provide more available blood to the heart to help maintain cardiac output. A common volumeAexpanding substance is plasma and possibly whole blood. Bou are caring $or a woman who was in severe automobile accident several days ago. She has several $ractures and internal in1uries. The exploratory laparotomy was success$ul in controlling the bleeding. (owever, today you $ind that this client is bleeding $rom her incision, short o$ breath, has a wea) thready pulse, has cold and clammy s)in, and hematuria. - :hat do you thin) is wrong with the client, and what would you expect to do about it= - These are typical signs and symptoms o$ D#2 crisis. *xpect to administer #? heparin to bloc) the $ormation o$ thrombin (2oumadin does not do this". (owever, the client described is already past the coagulation phase and into the hemorrhagic phase. (er management would be administration o$ clotting $actors along with palliative treatment o$ the symptoms as they arise. ((er prognosis is poor". C2;*DARC <uestions on 2%R o$ten deal with prioriti@ation o$ actions. Euestion+ :hat actions are re<uired $or each o$ the $ollowing situations= - A '4Ayear old motorcycle accident vistim with a ruptured artery i$ the leg is pulseless and apneic. - A F6Ayear old $irst time pregnant woman who arrests during labor. - A ,GAyear old with no pulse or respirations who is trapped in an overturned car, which is starting to catch $ire. - A 4Ayear old businessman who arrests two days a$ter a cervical laminectomy. :(*C T& S**H *.*R8*C2B .*D#2A; S*R?#2* (*.S" - The American (eart Association recommends that those with )nown angina pectoris see) emergency medical care i$ chest pain is C&T relieved by three nitroglycerin tablets 5 minutes apart over a ,5minute period. - A person with previously unrecogni@ed coronary disease experiencing chest pain persisting $or ' minutes or longer should see) emergency medical treatment. #t is important $or the nurse to stay current with the American (eart Association/s guidelines $or -asic ;i$e Support (-;S" by being certi$ied every two years as re<uired. 1 #$ one rescuer is per$orming 2%R, , ,5+' ratio o$ compression to ventilations is per$ormed $or 4 cycles, then reassess $or breathing and pulse. #$ two rescuers are per$orming 2%R, a ,5+' ratio is now recommended $or compressions to ventilations. %er$orm $or ,5 cycles with a ,0min compression rate. :hen trading o$$, start with compressions. #nitiate 2%R with -;S guidelines immediately, then move on to Advanced 2ardiac ;i$e Support (A2;S" guidelines. :hen signi$icant arterial acidosis is noted, try to reduce %2&' by increasing ventilation, which will correct arterial, venous, and tissue acidosis. -icarbonate may exacerbate acidosis b producing 2&'. Thus, the A2;S guidelines have recommended bicarbonate C&T be used unless hyper)alemia and0or preexisting acidosis is documented. #n$ants0prematures may have problems with the $ollowing that can predispose to arrest+ -eware o$ the I(/sJ K hypoxia, hypoglycemia, hypothermia, increased (L (metabolic and0or respiratory acidosis", hypercoagulability (i$ polycythemia exists". 2hanges is osmolarity cause shi$ts in $luid. The osmolarity o$ the extracellular $luid (*29" is almost entriely due to sodium. The osmolarity o$ intracellular $luid (#29" is related to many particles, with potassium being the primary electrolyte. The pressures in the *29 and the #29 are almost identical. #$ either *29 or #29 change in concentration, $luid shi$ts $rom the area o$ lesser concentration to the area o$ greater concentration. Dextrose ,! is a hypertonic solution and should be administered #?. Cormal saline is an isotonic solution and is used $or irrigations, such as bladder irrigations or #? $lush lines with intermittent #? medication. 7se only isotonic (neutral" solutions in irrigations, in$usions, etc., unless the speci$ic aim is to shi$t $luid into intracellular or extracellular spaces. %otassium imbalances are potentially li$eAthreatening, must be corrected immediately. A low magnesium o$ten accompanies a low HL, especially with the use o$ diuretics. 9luid ?olume De$icit+ Dehydration - *levated -7C+ The -7C measures the amount o$ urea nitrogen in the blood. 7rea is $ormed in the liver as the end product o$ protein metabolism. The -7C is directly related to the metabolic $unction o$ the liver and the excretory $unction o$ the )idneys. - 2reatinine, as with -7C, is excreted entirely by the )idneys and is there$ore directly proportional to renal excretory $unction. (owever, unli)e -7C, the creatinine level is a$$ected very little by dehydration, malnutrition, or hepatic $unction. The daily production o$ creatinine depends on muscle mass, which $luctuates very little. There$ore, it is a better test o$ renal $unction than is the -7C. 2reatinine is generally used in con1unction with the -7C test and they normally are in a ,+' ratio. - Serum osmolality measures the concentration o$ particles in a solution. #t re$ers to the $act that the same amount o$ solute is present, but the amount o$ solvent ($luid" is decreased. There$ore, the blood can be considered Imore concentrated.J - 7rine osmolality and speci$ic gravity increase. 2hec) the #? tubing container to determine the drip $actor because drip $actors vary. The most common drip $actors are ,, ,', ,5, and 6 drops per milliliter. A microdrip is 6 drops per milliliter. 9lushing a saline loc) re<uires approximately , M times the amount o$ $luid that the tubing will hold in order to e$$iciently $lush the tubing. R*.*.-*R to use sterile techni<ue to prevent complications such as in$iltration, emboli and in$ection. A p( o$ less than 6.N or more than G.N is C&T 2&.%AT#-;* :#T( ;#9*. The acronym R&.* can help you remember+ Respiratory, &pposite, .etabolic, *<ual. Review the order o$ blood $low to the heart+ - 7noxygenated blood $lows $rom the superior and in$erior vena cava into the right atrium, then to the right ventricle. #t $lows out o$ the heart through the pulmonary artery, to the lungs $or oxygenation. The pulmonary vein delivers oxygenated blood bac) to the le$t atrium, then to the le$t ventricle (largest, strongest chamber" and out the aorta. - Review the three structures that control the oneAway $low o$ blood through the heart+ 1. ?alves Atrioventricular valves Tricuspid (right side" .itral (le$t side" Semilunar valves %ulmonary (in pulmonary artery" Aortic (in aorta" '. 2ordae Tendinae F. %apillary muscles Since the T waves represents repolari@ation o$ the ventricle, this is a critical time in the heartbeat. This action represents a resting and regrouping stage so that the next heartbeat can occur. #$ de$ibrillation occurs during this phase, the heart can be thrust into a li$eAthreatening dysrhythmia. &bserve the client $or tolerance o$ the current rhythm. This in$ormation is the most important data the nurse can collect on the client with an arrythmia. R*.*.-*R to monitor the client as well as the machineO #$ the *H8 monitor shows a severe dysrhythmia, but the client is sitting up <uietly watching a T? without any sign o$ distress, assess to determine i$ the leads are attached properly. .ar)ing the operative site is re<uired $or procedures involving right0le$t distinctions, multiple structures ($ingers, toes", or levels (spinal procedures". Site mar)ing should be done with the involvement o$ the client. :ound dehiscence is separation o$ the wound edges and is more li)ely to occur with vertical incisions. #t usually occurs a$ter the early postoperative period, when the client/s own granulation tissue is Ita)ing overJ the wound, a$ter absorption o$ the sutures has begun. *visceration o$ the 2 wound is protrusion o$ intestinal contents (in an abdominal wound" and is more li)ely in clients who are older, diabetic, obese, or malnourished and have prolonged paralytic ileus. C2;*DARC items will $ocus on the nurse/s role in terms o$ the entire perioperative process. Sample+ A 4FAyear old mother o$ ' teenage daughters enters the hospital to have her gallbladder removed in a sameAday surgery using a scope instead o$ an incision. :hat nursing needs will dominate each phase o$ her short hospital stay= - %reparation phase+ *ducation about postoperative care, C%&, assist with meeting $amily needs. - &perative phase+ Assessment, management o$ the operative suite. - %ostAanesthesia phase+ %ain management, postAanesthesia precautions. - %ostAoperative phase+ %revent and assess $or complications, pain management, dietary restrictions, activity. (#? clients with tuberculosis re<uire respiratory isolation. Tuberculosis is the only real ris) to nonApregnant caregivers that is not related to a brea) in universal precautions (i.e., needle stic)s, etc.". STACDARD %R*2A7T#&CS+ - :ash hands, even i$ gloves have been worn to give care - :ear gloves (latex" $or touching blood or body $luids, or any nonAintact body sur$ace. - :ear gowns during any procedure that might generate splashes (changing clients with diarrhea". - 7se mas)s and eye protection during activity which might disperse droplets (suctioning". - Do not recap needles, dispose o$ in punctureAresistant containers. - 7se mouth piece $or resuscitation e$$orts. - Re$rain $rom giving care i$ you have open s)in lesions. 2aregivers who are pregnant may choose not to care $or a client with 2ytomegalovirus (2.?". %ediatric (#? is o$ten evidenced by lymphoid interstitial pneumonitis. The $ocus o$ C2;*DARC <uestions is li)ely to be assessment o$ early signs o$ the disease and management o$ complications associated with (#?. 9or narcotic induced respiratory depression, administer Caloxone .,mg to .4mg #? every 'AF minutes as needed, until ,.mg is achieved. 7se nonAinvasive methods $or pain management when possible+ - Relaxation techni<ues - Distraction - #magery - -io$eedbac) - #nterpersonal s)ills - %hysical care+ altering positions, touch, hot and cold applications. Carcotic analgesics are prepared $or pain relie$ because they bind to the various opiate receptor sites in the 2CS. .orphine is o$ten the pre$erred narcotic (R*.*.-*R+ it causes respiratory depression". &ther agonists are meperidine and methadone. Carcotic antagonists bloc) the attachment o$ narcotics to the receptors, such as Carcan (naloxone". &nce Carcan has been given, additional narcotics cannot be given until the Carcan e$$ects have passed. Do not ta)e away the coping style used in a crisis stateP D*C#A;. #t is a use$ul and needed tool at the initial stage $or some. Support, do not challenge, unless it hinders0bloc)s treatment K endangering the patient. MEDICAL SURGICAL NURSING RESPIRATORY SYSTEM 9ever can cause dehydration $rom excessive $luid loss in diaphoresis. #ncreased temperature also increases metabolism and the demand $or oxygen. (igh ris) $or pneumonia+ - Any person, who has altered level o$ consciousness, has depressed or absent gag re$lex and cough re$lexes, is susceptible to aspirating oropharyngeal secretions. (Alcoholics, anesthesi@ed individuals, those with brain in1ury, drug overdose, or stro)e victims". - :hen $eeding, raise the head o$ the bed and position the client on side K not on bac). -ronchial breath sounds are heard over areas o$ density or consolidation. Sound waves are easily transmitted over consolidated tissue. (ydration K enables li<ui$ication o$ mucous trapped in the bronchioles and alveoli, $acilitating expectoration. *ssential $or the client experiencing $ever. #mportant because F to 4 ml o$ $luid are lost daily by the lungs through evaporation. #rritability and restlessness are early signs o$ cerebral hypoxia K the client is not getting enough oxygen to the brain. %neumonia preventatives+ - *lderly+ $lu shots> pneumonia immuni@ations> avoiding sources o$ in$ection and indoor pollutants (dust, smo)e, and aerosols"> do not smo)e. - #mmunosuppressed and debilitated persons+ in$ection avoidance, sensible nutrition, ade<uate inta)e, balance o$ rest and activity. - 2omatose and immobile persons+ elevate head o$ bed to $eed> turn $re<uently. 2ompensation occurs over time in clients with chronic lung disease, and arterial blood gases (A-8s" are altered. #t is imperative that baseline data are obtained on the client. %roductive cough and com$ort can be $acilitated by SemiA 9owler/s or high 9owler/s positions, which lessen pressure on the diaphragm $rom abdominal organs. 8astric distention becomes a priority in these clients because it elevates the diaphragm and inhibits lung expansion. 3 %in) pu$$er+ -arrel chest is indicative o$ emphysema and is caused by use o$ accessory muscles to breathe, which causes the person to wor) harder to breathe, but the amount o$ &' ta)en in in ade<uate to oxygenate the tissues. -lue bloater+ insu$$icient oxygenation occurs with chronic bronchitis and leads to generali@ed cyanosis and o$ten rightA sided heart $ailure. 2ells o$ the body depend on oxygen to carry out their $unctions. #nade<uate arterial oxygenation is mani$ested by cyanosis and slow capillary re$ill (5F seconds". A chronic sign is clubbing o$ the $ingernails, and a late sign is clubbing o$ the $ingers. 2aution must be used in administering &' to 2&%D client. The stimulus to breathe is hypoxia (hypoxic drive" not the usual hypercapnia, the stimulus to breathe $or healthy persons. There$ore, i$ too much oxygen is given, the client may stop breathingO (ealth %romotion+ - *ating consumes energy needed $or breathng. &$$er mechanically so$t diets, which do not re<uire as much chewing and digestion. Assist with $eeding i$ needed. - %revent secondary in$ections K avoid crowds, contact with persons who have in$ectious diseases, and respiratory irritants (tobacco smo)e". - Teach client to report any change in characteristics o$ sputum. - *ncourage client to hydrate well and to obtain immuni@ations needed ($lu and pneumonia". :hen as)ed to prioriti@e nursing actions, use the A-2 rule+ - Airway $irst - Then breathing - Then circulation ;oo) and listen. #$ breath sounds are clear, but the client is cyanotic and lethargic, ade<uate oxygenation is not occurring. The )ey to respiratory status assessment o$ breath sounds as well as visuali@ation o$ the client. -reath sounds are better Idescribed,J not named, e.g., sounds should be described as Icrac)les,J Iwhee@e,J IhihgApitched whistling sound,J rather than Irales,J Irhonchi,J etc., which may not mean the same thing to each clinical pro$essional. :atch $or C2;*DARC <uestions that deal with oxygen delivery. #n adults, &' must bubble through some type o$ water solution so it can be humidi$ied i$ given at 34 ;0min or delivered directly to the trachea. #$ given at , to 4 ;0min or by mas) or nasal prongs, the oropharynx and nasal pharynx provide ade<uate humidi$ication. :ith cancer o$ the larynx, the tongue and mouth o$ten appear white, gray, dar) brown, or blac), and may appear patchy. Tracheostomy care involves cleaning the inner cannula, suctioning, and applying a clean dressing. Air entering the lungs is humidi$ied along the nasoAbronchial tree. This natural humidi$ying pathway is gone $or the client who has had a laryngectomy. #$ the air is not humidi$ied be$ore entering the lungs, secretions tend to thic)en and become crusty. A laryngectomy tube has a larger lumen and is shorter than the tracheostomy tube. &bserve the client $or any signs o$ bleeding or occlusion, which are the greatest immediate postoperative ris)s ($irst '4 hours". 9ear o$ cho)ing is very real $or laryngectomy clients. They cannot cough as be$ore because the glottis is gone. Teach the Iglottal stopJ techni<ue to remove secretions (ta)e a deep breath, momentarily occlude the tracheostomy tube, cough, and simultaneously remove the $inger $rom the tube". T- SH#C T*ST+ a positive T- s)in test is exhibited by an induration ,mm or greater in diameter 4N hours a$ter s)in test. Anyone who has received a -28 vaccine will have a positive s)in test and must be evaluated using a chest xAray. Teaching is very important with the T- client. Drug therapy is usually long term (Q months or longer". #t is essential that the client ta)e the medications as prescribed $or the entire time. S)ipping doses or prematurely terminating the drug therapy can result in a public health ha@ard. T*A2(#C8 %&#CTS K - Ri$ampin+ Reduces e$$ectiveness o$ oral contaceptives> should use other birth control methods during treatment> gives body $luids orange tinge> stains so$t contacts. - #sonia@id (#C("+ #ncreases Dilantin levels. - *thambutal+ ?ision chec) be$ore starting therapy and monthly> may have to ta)e , to ' years longer. - Teach rationale $or combination drug therapy to increase compliance. Resistance develops more slowly i$ several antiAT- drugs given, instead o$ 1ust one drug at a time. Some tumors are so large that they $ill entire lobes o$ the lung. :hen removed, large spaces are le$t. 2hest tubes are not usually used with these clients because it is help$ul i$ the mediastinal cavity, where the lung used to be, $ills up with $luid. This $luid helps prevent a shi$t o$ the remaining chest organs to $ill the empty space. #$ the chest tube remains disconnected, do not clampO #mmediately place the end o$ the tube in a container o$ sterile saline or water until a new drainage system can be connected. #$ the chest tube is accidentally removed $rom the client, the nurse should apply pressure immediately with an occlusive dressing and noti$y the healthcare provider. 2hest Tube C2;*DARC content+ 9luctuations (tidaling" in the $luid will occur i$ there is no external suction. These $luctuating movements are a good indicator that the system is intact and should move upward with each inspiration and downward with each expiration. #$ $luctuations cease, chec) $or )in)ed tubing, accumulation o$ $luid in the tubing, occlusions, or change in the client/s position, since expanding lung tissue may be occluding the tube opening. Remember, when external suction is applied the $luctuations cease. .ost hospitals D& C&T .#;H chest tubes as a means o$ clearing or preventing clots K it is too easy to remove chest tubes. .ediastinal tubes may have orders to be stripped because o$ location, compared to larger thoracic cavity tubes. 4 ?arious pathophysiological conditions can be related to the nursing diagnosis I#ne$$ective -reathing %atterns.J ,. #nability o$ air sacs to $ill and empty properly (emphysema, cystic $ibrosis" '. &bstruction o$ the air passages (carcinoma, asthma, chronic bronchitis" F. Accumulation o$ $luid in the air sacs (pneumonia" 4. Respiratory muscle $atigue (2&%D, pneumonia" RENAL SYSTEM Cormally, )idney excrete approximately ,ml o$ urine per )g o$ body weight per hour, which is about , to ' liters in a '4Ahour period. *lectrolytes are pro$oundly a$$ected by )idney problems. There must be a balance between extracellular $luid and intracellular $luid to maintain homeostasis. A change in the number o$ ions or in the amount o$ $luid will cause a shi$t in one direction or the other. Sodium and chloride are the primary extracellular ions. %otassium and phosphate are the primary intracellular ions. #n some cases, persons in AR9 may not experience the oliguric phase but may progress directly to diuretic phase during which the urine output may be as much as , liters per day. -ody weight is a good indicator o$ $luid retention and renal status. &btain accurate weights on all clients with renal $ailure K done on the same scale at the same time every day. 9luid ?olume Alterations 9luid *xcess symptoms+ - Dyspnea - Tachycardia - Rugular vein distention - %eripheral edema - %ulmonary edema 9luid de$icit symptoms+ - Decreased urine output - Reduction in body weight - Decreased body turgor - Dry mucous membranes - (ypotension - Tachycardia :atch $or signs o$ hyper)alemia+ di@@iness, wea)ness, cardiac irregularities, muscle cramps, diarrhea, and nausea. %otassium has a critical sa$e range (F.5 to 5. m*g0;" because it a$$ects the heart, and any imbalance must be corrected by medications or dietary modi$ication. ;imit high potassium $oods (bananas, avocados, spinach, $ish" and salt substitutes, which are high in potassium. 2lients with renal $ailure retain sodium. :ith water retention, the sodium becomes diluted and serum levels may appear near normal. :ith excessive water retention, the sodium levels appear decreased dilution". ;imit $luid and sodium inta)e in AR9 clients. During oliguric phase, minimi@e protein inta)e. :hen the -7C and creatinine return to normal, aR9 is determined to be resolved. Accumulation o$ waste products $rom protein metabolism is the primary cause o$ uremia. %rotein must be restricted in 2R9 clients. (owever, i$ protein inta)e is inade<uate, a negative nitrogen balance occurs causing muscle wasting. The glomerular $iltration rate (89R" is most o$ten used as an indicator o$ level o$ protein consumption. D#A;BS#S 2&?*R*D -B .*D#2AR*+ - All persons in the 7nited States are eligible $or .edicare as o$ their $irst day o$ dialysis under special *nd Stage Renal Disease $unding. - .edicare card will indicate *SRD. - Transplantation is covered by .edicare procedure> coverage terminates six months postoperative i$ dialysis is no longer re<uired. %rotein inta)e is restricted until blood chemistry shows ability to handle protein catabolites+ urea, creatinine. *nsure high calorie inta)e so protein is spared $or its own wor)+ give hard candy, 1elly beans, $lavored carbohydrate powders. As )idneys $ail, medications must o$ten be ad1usted. &$ particular importance is digoxin toxicity since digitalis preparations are excreted by the )idneys. Signs o$ toxicity in adults include nausea, vomiting, anorexia, visual disturbances, restlessness, headache, cardiac arrythmias, and pulse 56 beats per minute (bradycardia". The ma1or di$$erence between dailysate $or hemodialysis and peritoneal dialysis is the amount o$ glucose. %eritoneal dialysis dialysate is much higher in glucose. 9or this reason, i$ the dialysate is le$t in the peritoneal cavity too long, hyperglycemia may occur. The )ey to resolving 7T# with most antibiotics is to )eep the blood level o$ the antibiotic constant. #t is important to tell the client to ta)e the antibiotics roundAtheAcloc) and not s)ip doses so that a consistent blood level can be maintained $or optimal e$$ectiveness. ;ocation o$ the pain can help determine location o$ the stone. - 9lan) pain usually means the stone is in the )idney or upper ureter. #$ it radiates in the abdomen or scrotum, the stone is li)ely to be in the ureter or bladder. - *xcruciating, spasticAtype pain is called colic. - During )idney stone attac)s, it is pre$erable to administer pain medications at regularly scheduled intervals rather than %RC to prevent spasm and optimi@e com$ort. %ercutaneous nephrostomy+ A needle0catheter is inserted through the s)in into the calyx o$ the )idney. The stone may be dissolved by percutaneous irrigation with a li<uid which will dissolve the stone, or ultrasonic sound waves (lithotripsy" can be directed through the needle0catheter to brea) up the stone which then can be eliminated through the urinary tract. -ladder spasms $re<uently occur a$ter T7R%. #n$orm the client that the presence o$ the oversi@ed balloon on the 5 catheter (F to 45 cc in$late" will cause a continuous $eeling o$ needing to void. The client should not try to avoid around the catheter since this can precipitate bladder spasms. .edications to reduce or prevent spasms should be given. #nstillation o$ hypertonic or hypotonic solution into a body cavity will cause a shi$t in cellular $luid. 7se only sterile saline $or bladder irrigation a$ter T7R% since the irrigation must be isotonic to prevent $luid and electrolyte imbalance. #n$orm the client prior to discharge that some bleeding is expected a$ter T7R%. ;arge amounts o$ blood or $ran) bright bleeding should be reported. (owever, it is normal $or the client to pass small amounts o$ blood during the healing process as well as small clots. (e should rest <uietly and continue drin)ing large amounts o$ $luid. CARDIOVASCULAR SYSTEM :hat is the relationship o$ the )idneys to the cardiovascular system= - The )idneys $ilter about a liter o$ blood per minute - #$ cardiac output is decreased, the amount o$ blood going through the )idneys is decreased> urinary output is decreased. There$ore, a decreased urinary output may be a sign o$ cardiac problems. - :hen the )idneys produce and excrete .5 ml o$ urine per )g o$ body weight or average F ml0hr output, the blood supply is considered to be minimally ade<uate to per$use the vital organs. Angina is caused by myocardial ischemia. :hich cardiac medications would be appropriate $or acute angina= - Digoxin K Cot appropriate K #ncreases the strength and contractility o$ the heart muscle> the problem in angina is that the muscle is not receiving enough oxygen. Digoxin will not help. - Citroglycerin K Appropriate K 2auses dilation o$ the coronary arteries, allowing more oxygen to get to the heart muscle. - Atropine K Cot appropriate K #ncreases heart rate by bloc)ing vagal stimulation, which suppresses the heart rate. Does not address the lac) o$ &' to the heart muscle. - %ropanolol (#nderal" K Cot appropriate K $or acute angina attac)> however, is appropriate $or longAterm management o$ stable angina because it acts as a betaAbloc)er to control vasoconstriction. -lood pressure is created by the di$$erence in the pressure o$ the blood as it leaves the heart and the resistance it meets $lowing out to the tissues. There$ore, any $actor that alters cardiac output or peripheral vascular resistance will alter blood pressure. Diet and exercise, smo)ing cessation, weight control, and stress management can control many $actors that in$luence the resistance blood meets as it $lows $rom the heart. Remember the ris) $actors $or hypertension+ heredity, race, age, alcohol abuse, increased salt inta)e, obesity, and use o$ oral contraceptives. The number one cause o$ 2?A with hypertensive clients is nonAcompliance with medication regime. (ypertension is o$ten symptomless, and antihypertensive medications are expensive and have side e$$ects. Studies have shown that the more clients )now about their antihypertensive medications, the more li)ely they are to ta)e them K teaching is important. Decreased blood $low results in diminished sensation in the lower extremities. Any heat source can cause severe burns be$ore the client actually reali@es the damage is being done. A client is admitted with severe chest pain and states that he $eels a terrible, tearing sensation in his chest. (e is diagnosed with a dissecting aortic aneurysm. :hat assessment should the nurse obtain in the $irst $ew hours= - ?ital signs <, hour - Ceurological vital signs - Respiratory status - 7rinary output - %eripheral pulses During aortic aneurysm repair, the large arteries are clamped $or a period o$ time and )idney damage can result. .onitor daily -7C and creatinine levels. Cormal -7C is , to ' mg0dl and normal creatinine is '+,. :hen this ratio increases or decreases, suspect renal problems. A positive (omen/s sign is considered an early indication o$ thrombophlebitis. (owever, it may also indicate muscle in$lammation. #$ a deep vein thrombosis has been con$irmed, a (oman/s sign should not be elicited because o$ the increased ris) o$ emboli@ation. (eparin prevents conversion o$ $ibrinogen to $ibrin and prothrombin to thrombin, thereby inhibiting clot $ormation. Since the clotting mechanism is prolonged, do not cause tissue trauma which may lead to bleeding when giving heparin subcutaneously. Do not massage area or aspirate> give in the abdomen between the pelvic bones> ' inches $rom umbilicus> rotate sites. (*%AR#C+ - Antagonist+ %rotamine Sul$ate - ;A-+ %TT or A%TT determines e$$icacy - Heep ,.5 to '.5 times normal control 2&7.AD#C+ - Antagonist+ ?itamin H - ;A-+ %T determines e$$icacy - Heep ,.5 to '.5 times normal control #CR+ Desirable therapeutic level usually ' to F seconds (re$lects how long it ta)es a blood sample to clot". A holter monitor o$$ers continuous observation o$ the client/s heart rate. To ma)e assessment o$ the rhythm strips, most meaning$ul, teach the client to )eep a record o$+ - .edication times and doses - 2hest pain episodes K type and duration - ?alsalva maneuver (straining at stool, snee@ing, coughing" - Sexual activity - *xercise 2ardioversion is the delivery o$ synchorni@ed electrical shoc) to the myocardium. Di$$erentiate in synchronous and asynchronous pacema)ers+ 6 - Synchronous or demand pacema)er $ires only when the client/s heart rate $alls below a rate set on the generator. - Asynchronous or $ixed pacema)er $ires at a constant rate. Restricting sodium reduces salt and water retention, thereby reducing vascular volume and preload. D#8#TA;#S+ - Side e$$ects o$ digitalis are increased when the client is hypo)alemic. - (as a negative chronotropic e$$ect, i.e., it shows the heart rate. (old the digitalis i$ the pulse rate is 56, 3,', or has mar)edly changed rhythm. - -radycardia, tachycardia, or dysrhythmias may be signs o$ digitalis toxicity+ these signs include nausea, vomiting, and headache in adults. - #$ withheld, consult with physician. #n$ective endocarditis damage to heart valves occurs with the growth o$ vegetative lesions on valve lea$lets. These lesions pose a ris) o$ emboli@ation> erosion0per$oration o$ the valve lea$lets> or abscesses within ad1acent myocardial tissue. ?alvular stenosis or regurgitation (insu$$iciency", most commonly o$ the mitral valve, can occur depending upon the type o$ damage in$licted by the lesions, leading to symptoms o$ le$t K or rightAsided heart $ailure. Acute and Subacute #n$ective *ndocarditis A There are ' types o$ in$ective endocarditis+ - Acute , which o$ten a$$ects individuals with previously normal hearts and healthy valves, and carries a high mortality rate - Subacute , which typically a$$ects individuals with preexisting conditions, such as rheumatic heart disease, mitral valve prolapse, or immunosuppression. #ntravenous drug abusers are at ris) $or both acute and subacute bacterial endocarditis. :hen this population develops Subacute #n$ective *ndocarditis, the valves on the right side o$ the heart (tricuspid and pulmonic" are typically a$$ected due to the introduction o$ common pathogens which coloni@e on the s)in (S. epidermis and 2andida" into the venous system. %ericarditis K presence o$ a $riction rub is an indication o$ pericarditis (in$lammation o$ the lining o$ the heart". ST segment elevation and T wave inversion are also signs o$ pericarditis. :ith mitral valve stenosis, blood is regurgitated bac) into the le$t atrium $rom the le$t ventricle. #n early period, there may be no symptoms> but, as the disease progresses, the client will exhibit excessive $atigue, dyspnea on exertion, orthopnea, dry cough, hemoptysis, or pulmonary edema. There will be a rumbling apical diastolic murmur, and atrial $ibrillation is common. GASTROINTESTINAL SYSTEM A 9owler/s or semiA9owler/s position is bene$icial in reducing the amount o$ regurgitation as well as preventing the encroachment o$ the stomach tissue upward through the opening in the diaphragm. Stress can cause or exacerbate ulcers. Teach stress reduction methods and encourage those with a $amily history o$ ulcers to obtain medical surveillance $or ulcer $ormation. 2;#C#2A; .AC#9*STAT#&CS &9 8# -;**D#C8+ - %allor+ con1uctival, mucous membranes, nail beds - Dar), tarry stools - -right red or co$$eeAground emesis - Abdominal mass or bruit - Decreased -%, rapid pulse, cool extremities (shoc)". The 8# tract usually accounts $or only , to ' ml $luid loss per day, although it $ilters up to N liters per day. ;arge $luid losses can occur i$ vomiting and0or diarrhea exists. &piate drugs tend to depress gastric motility. (owever, they should be given with care, and those receiving them should be closely monitored because a distended intestinal wall accompanied by decreased muscle tone may lead to intestinal per$oration. Diverticulosis is the presence o$ pouches in the wall o$ the intestine. There is usually do discom$ort, and the problem goes unnoticed unless seen on radiological examination (usually prompted by some other condition". Diverticulitis is an in$lammation o$ the diverticula (punches", which can lead to per$oration o$ the bowel. A client admitted with complaints o$ severe lower abdominal pain, cramping, and diarrhea is diagnosed with diverticulitis. :hat are the nutritional needs o$ this client throughout recovery= - Acute phase K C%& graduating to li<uids. - Recovery phase K no $iber or $oods that irritate the bowel. - .aintenance phase K highA$iber diet, with bul)A$orming laxatives to prevent pooling o$ $oods in the pouches where they can become in$lamed. Avoid small, poorly digested $oods such as popcorn, nuts, seeds, etc. -owel obstructions+ - .echanical+ due to disorders outside the bowel (hernia, adhesions", due to disorders within the bowel (tumors, diverticulitis", or due to bloc)age o$ the lumen in the intestine (intussusception, gall stone". - ConAmechanical+ paralytic ileus, which does not involve any actual physical obstruction, but results $rom inability o$ the bowel itsel$ to $unction. -lood gas analysis will show al)alotic state i$ the bowel obstruction is high in the small intestine where gastric acid is secreted. #$ the obstruction is in the lower bowel where base solutions are secreted, the blood will be acidic. A client admitted with complaints o$ constipation, thready stools and rectal bleeding over the past $ew months is diagnose with a rectal mass. :hat are the nursing priorities $or this client= - C%& - C8 tube (possibly an intestinal tube such as a .illerAAbbott" - #? $luids - Surgical preparations o$ bowel (i$ obstruction is complete" - Teaching (preoperative, nutrition, etc." Diet recommended by the American 2ancer Society to prevent bowel cancer+ 7 - *at more cruci$erous vegetables ($rom the cabbage $amily such as broccoli, cauli$lower, -russels sprouts, cabbage, and )ale". - #ncrease $iber inta)e. - .aintain average body weight - *at less animal $at. A.*R#2AC 2AC2*R S&2#*TB R*2&..*CDAT#&CS $or early detection o$ 2olon 2ancer+ - A digital rectal examination every year a$ter 4. - A stool blood test every year a$ter 5. - A sigmoidoscopy examination every F to 5 years a$ter the age o$ 5, based on the advice o$ a physician. 2ancer o$ the colon is the most common cancer in the 7S when considering men and women together. An early sign is the rectal bleeding. *ncourage patients 5 years o$ age or older, or those with increased ris) $actors, to be screened yearly with $ecal occult blood testing. Routine colonoscopy at 5 is also recommended. 2;#C#2A; .AC#9*STAT#&CS &9 RA7CD#2* - Bellow s)in, sclera, and0or mucous membranes (bilirubin in s)in" - Dar)Acolored urine (bilirubin in urine" - 2hal)y or clayAcolored stools (absence o$ bilirubin in stools" 9etor hepaticus is a distinctive breath odor o$ chronic liver disease. #t is characteri@ed by a $ruity or musty odor which results $rom the damaged liver/s inability to metaboli@e and detoxi$y mercaptan which is produced by the bacterial degradation o$ metionine, a sul$urous amino acid. 9or treatment o$ ascities, paracentesis and peritoneovenous shunts (;a?een and Denver shunts" may be indicated. *sophageal varices may rupture and cause hemorrhage. #mmediate management includes insertion o$ an esophagogastric balloon tamponade K a -la)emoreA Sengsta)en or .innesota tube. &ther therapies include vasopressors, vitamin H, coagulation $actors, and blood trans$usions. Ammonia is not bro)en down as usual in the damaged liver> there$ore, the serum ammonia level rises. %R&?#D* AC *C?#R&C.*CT 2&CD72#?* T& *AT#C8 $or clients who are anorexic and0or nauseated+ - Remove strong odors immediately> they can be o$$ensive and increase nausea. - *ncourage client to sit up $or meals> this can decrease the propensity to vomit. - Serve small, $re<uent meals. ;iver tissue is destroyed by hepatitis. Rest and ade<uate nutrition are necessary $or regeneration o$ liver tissue being destroyed by the disease. Since many drugs are metaboli@ed in the liver, drug therapy must be scrutini@ed care$ully. 2aution the client that recovery ta)es many months, and previously ta)en medications should not be resumed without the healthcare provider/s directions. Acute pancreatic pain is located retroperitoneally. Any enlargement o$ the pancreas causes the peritoneum to stretch tightly. There$ore, sitting up or leaning $orward will reduce the pain. 9ollowing an endoscopic retrogade cholangiopancreatography (*R2%", the client may $eel sic). The scope is placed in the gallbladder and the stones are crushed and le$t to pass on their own. These clients may be prone to pancreatitis. ConAsurgical management o$ the client with cholecystitis includes+ - ;owA$at diet - .edications $or pain and clotting i$ re<uired - Decompression o$ the stomach via C8 tube ENDOCRINE SYSTEM Thyroid storm is a li$eAthreatening event that occurs with uncontrolled hyperthyroidism due to 8rave/s disease. Symptoms include $ever, tachycardia, agitation, anxiety, and hypertension. - %rimary nursing interventions include maintaining an airway and ade<uate aeration. - %ropylthiouracil (%T7" or methima@ole (Tapa@ole" are antithyroid drugs used to treat thyroid storm. %ropanolol (#nderal" may be given to decrease excessive sympathetic stimulation. %ostAoperative thyroidectomy+ be prepared $or the possibility o$ laryngeal edema. %ut a tracheostomy set at bedside along with oxygen and a suction machine> 2aLL gluconate easily accessible. Cormal serum calcium is Q. to ,.5 m*<0;. The best indicator o$ parathyroid problems is a decrease in the client/s calcium compared to the preoperative value. #$ two or more parathyroid glands have been removed, the chance o$ tetany increases dramatically+ - .onitor serum calcium levels (Q. to ,.5 mg0dl is normal range" - 2hec) $or tingling o$ toes, $ingers, and around the mouth. - 2hec) $or 2hvoste)/s sign (tap over the parotid gland and which $or twitching o$ lip S positive" - 2hec) Trousseau/s sign (carpopedal spasm a$ter in$lating -% cu$$ above systolic pressure S positive". .yxedema coma can be precipitated by acute illness, withdrawal o$ thyroid medication, anesthesia, use o$ sedatives, or hypoventilation (with the potential $or respiratory acidosis and carbondioxide narcosis". The airway must be )ept patent, and ventilator support as indicated. .any people ta)e steroids $or a variety o$ conditions. C2;*DARC <uestions o$ten $ocus on the need to teach clients the importance o$ precisely $ollowing the prescribed regimen. They should be cautioned against suddenly stopping the medications and be in$ormed that it is necessary to taper o$$ ta)ing steroids. ADD#S&CJS 2R#S#S #S A .*D#2A; *.*R8*C2B+ -rought on by sudden withdrawal o$ steroids or a stress$ul event (trauma, severe in$ection" 8 - ?ascular 2ollpase+ (ypotension and tachycardia occur> administer #? $luids at rapid rate until stabili@ed. - (ypoglycemia+ Administer #? glucose - AD.#C#ST*R %AR*CT*RA; (BDR&2&RT#S&C*+ *ssential $or reversing the crisis. - A;D&ST*R&C* R*%;A2*.*CT+ Administer $ludrocortisone acetate(9lorine$" %& (only available as oral preparation" with simultaneous administration o$ salt (sodium chloride" i$ client has a sodium de$icit. Teach clients to ta)e steroids with meals to prevent gastric irritation. They should never s)ip doses. #$ they have nausea or vomiting $or more than ,' to '4 hours, they should contact the physician. :hy do diabetics have trouble with wound healing= (igh blood glucose contributes to damage o$ the smallest vessels, the capillaries. This damage causes permanent capillary scarring, which inhibits the normal activity o$ the capillary. This phenomenon causes disruption o$ capillary elasticity and promotes problems such as diabetic retinopathy, poor healing or brea)s in the s)in, cardiovascular abnormalities, etc. 8lycosylated (gb ((gb A,2" - #ndicates glucose control over previous ,' days (li$e o$ R-2" - ?aluable measurement o$ diabetes control. The body/s response to illness0stress is to produce glucose. There$ore, any illness results in hyperglycemia. #$ in doubt whether the client is hyperglycemic or hypoglycemic, treat $or hypoglycemia. S*;9A.&C#T&R#C8 -;&&D 8;72&S* (S.-8" - %rovides tight glucose control thereby decreasing the potential $or longAterm complications - Techni<ue is speci$ic to each meter i$ meter is used. - .onitor be$ore meals, at bedtime, and any time symptoms occur. - Record results and report to healthcare provider at time o$ visit. MUSCULOSKELETAL SYSTEM A client comes to the clinic complaining o$ morning sti$$ness, weight loss, and swelling o$ both hands and wrists. Rheumatoid arthritis is suspected. :hich methods o$ assessment might the nurse use and which methods would the nurse not use= - 7se inspection, palpation, and strength testing. - Do not use range o$ motion (this activity promotes pain because R&. is limited". #n the 1oint, the normal cartilage becomes so$t, $issures and pitting occur, and the cartilage thins. Spurs $orm and in$lammation sets in. The result is de$ormity mar)ed by immobility, pain, and muscle spasm. The prescribed treatment regimen is corticosteroids $or the in$lammation> splinting, immobili@ation, and rest $or 1oint de$ormity> and CSA#DS $or the pain. Synovial tissues line the bone o$ the 1oints. #n$lammation o$ this lining causes destruction o$ tissue and bone. *arly detection o$ rheumatoid arthritis can decrease the amount o$ bone and 1oint destruction. &$ten the disease will go into remission. Decreasing the amount o$ bone and 1oint destruction will reduce the amount o$ disability. :hat activity recommendations should the nurse provide a client with rheumatoid arthritis= - Do not exercise pain$ul, swollen 1oints. - Do not exercise any 1oint to the point o$ pain. - %er$orm exercises slowly and smoothly> avoid 1er)y movements. C2;*DARC <uestions o$ten $ocus on the $act that avoiding sunlight is )ey in management o$ lupus erythematosus K this is what di$$erentiates it $rom other connective tissue diseases. Degenerative 1oint disease (DRD" and osteoarthritis are o$ten described as the same disease, and indeed they both result in hypertrophic changes in the 1oints. (owever, they di$$er in that osteoarthritis is an in$lammatory disease and DRD is characteri@ed by nonAin$lammatory degeneration o$ the 1oints. %ostmenopausal, thin, 2aucasian women are at highest ris) $or development o$ osteoporosis. *ncourage exercise, a diet high in calcium, and supplemental calcium. :hile T7.S is an excellent source o$ calcium, it is also high in sodium and hypertensive or edematous individuals should see) another source $or supplemental calcium. The main cause o$ $ractures in the elderly, especially women, is osteoporosis. The main $racture sites seem to be hip, vertebral bodies, and 2olles/ $racture o$ $orearm. C2;*DARC <uestions $ocus on sa$ety precautions. #mproper use o$ assistive devices can be very ris)y. :hen using a nonAwheeled wal)er, the client should li$t and move the wal)er $orward, then ta)e a step into it. The client should avoid scooting the wal)er or shu$$ling $orward into it which ta)es more energy and is less stable than a single movement. :hat type o$ $racture is more di$$icult to heal, an extra capsular $racture (below the nec) o$ the $emur" or an intracapsular $racture (in the nec) o$ the $emur"= - The blood supply enters the $emur below the nec) o$ the $emur. There$ore, an intraAcapsular $racture is much more harder to heal and has a greater li)elihood o$ necrosis since it is cut o$$ $rom the blood supply. The ris) o$ a $at embolism, a syndrome in which $at globules migrate into the bloodstream and combine with platelets to $orm emboli, is greatest in the $irst F6 hours a$ter a $racture. #t is more common in clients with multiple $ractures, $ractures o$ long bones, and $ractures o$ the pelvis. The initial symptom of a fat embolism is confusion due to hypoxemia (chec) blood gases $or %&'". Assess $or respiratory distress, restlessness, irritability, $ever, and petechiae. #$ an embolus is suspected, noti$y physician STAT, draw blood gases, administer oxygen, and assist with endotracheal intubation. #n clients with hip $ractures, thromboembolism is the most common complication. %revention includes passive range o$ motion exercises, elastic stoc)ing use, elevation o$ the $oot 9 o$ the bed '5 degrees to increase venous return, and lowA dose hepatin therapy. 2lients with $ractures, casts, or edema to the extremities need $re<uent neurovascular assessment distal to the in1ury. S)in color, temperature, sensation, capillary re$ill, mobility, pain and pulses should be assessed. Assess the I5 %sJ o$ neurovascular $unctioning+ pain, paresthesia, pulse, pallor and paralysis. &rthopedic wounds have a tendency to oo@e more than other wounds. A suction drainage device usually accompanies the client to the postoperative $loor. 2hec) drainage o$ten. A big problem a$ter 1oint replacement is in$ection. 9ractures o$ bone predispose the client to anemia, especially i$ long bones are involved. 2hec) hemtocrit every F to 4 days to monitor erythropoiesis. #nstruct the client not to li$t the leg upward $rom a lying position or to elevate the )nee when sitting. This upward motion can pop the prosthesis out o$ the soc)et. #mmobile clients are prone to complications+ s)in integrity problems, $ormation o$ urinary calculi (may limit mil) inta)e", and venous thrombosis (may be on prophylactic anticoagulants". The residual limb should be elevated on one pillow. #$ the residual limb (stump" is elevated too high, the elevation can cause contracture. NEUROSENSORY SYSTEM 8laucoma is o$ten painless and symptomA$ree. #t is usually pic)ed up as part o$ a regular eye exam. *ye drops are used to cause pupil constriction since movement o$ the muscles to constrict the pupil also allows a<ueous humor to $low out, thereby decreasing the pressure in the eye. %ilocarpine is o$ten used. 2aution client that vision may be blurred , to ' hours a$ter administration o$ pilocarpine and adaptation to dar) environments is di$$icult because o$ pupillary constriction (desired e$$ect o$ the drug". There is an increased incidence o$ glaucoma in the elderly population. &lder clients are prone to problems associated with constipation. There$ore, the nurse should assess these clients $or constipation and postoperative complications associated with constipation, and implement a plan o$ care directed at prevention, and, i$ necessary, treatment $or constipation. The lens o$ the eye is responsible $or pro1ecting light, which enters onto the retina so that images can be discerned. :ithout the lens, which becomes opa<ue with cataracts, light cannot be $iltered and vision is blurred. :hen the cataract is removed, the lens is gone, ma)ing prevention o$ $alls important. #$ the lens is replaced with an implant, vision is better than i$ a contact lens is used (some visual distortion" or i$ glasses are used (greater visual distortion K everything has a curved shape". The ear consists o$ three parts+ the external ear, middle ear, and the inner ear. #nner ear disorders, or disorders o$ the sensory $ibers going to the 2CS., o$ten are neurogenic in nature and may not be helped with a hearing aid. *xternal and middle ear problems (conductive" may result $rom in$ection, trauma or wax buildup. These types o$ disorders are treated more success$ully with hearing aids. C2;*DARC <uestions o$ten $ocus on communicating with older adults who are hearing impaired. - Spea) in a lowApitched voice, slowly, and distinctly. - Stand in $ront o$ the person with the light source behind the client. - 7se visual aids i$ available. NEUROLOGICAL SYSTEM 7se o$ the 8lasgow 2oma Scale eliminates ambiguous terms to describe neurologic status such as lethargic, stuporous, or obtunded. Almost every diagnosis in the CACDA $ormat is applicable, as severely neurologically impaired persons re<uire total care. 2lients with an altered state o$ consciousness are $ed by enteral routes since the li)elihood o$ aspiration with oral $eedings is great. Residual $eeding is the amount o$ previous $eeding still in the stomach. The presence o$ , ml residual in adults usually indicates poor gastric emptying and the $eeding should be held. %aralytic ileus is common in comatose clients. 8astric tube aids in gastric decompression. Any client on bedrest0immobili@ed must have range o$ motion exercises o$ten and very $re<uent position changes. Do not leave the client in any one position $or longer than ' hours. Any position that decreases venous return is dangerous, i.e., sitting with dependent extremities $or long periods. #$ temperature elevates, ta)e <uic) measures to decrease it since $ever increases cerebral metabolism and can increase cerebral edema. Sa$ety measures $or immobili@ed clients+ - %revent s)in brea)down with $re<uent turning. - .aintain ade<uate nutrition. - %revent aspiration with slow, small $eedings or C8 $eedings. - .onitor neurological signs to detect the $irst signs that intracranial pressure may be increasing. - %rovide range o$ motion exercises to prevent de$ormities. - %revent respiratory complications K $re<uent turning and positioning $or optimal drainage.
Restlessness may indicate a return to consciousness but can also indicate anoxia, distended bladder, covert bleeding, or increasing cerebral anoxia. Do not overAsedate, and report any symptoms o$ restlessness. The $orces o$ impact in$luence the type o$ head in1ury. They include acceleration in1ury, which is caused by the head in motion, and deceleration in1ury, which occurs when the head 10 stops suddenly. (elmets are a 8R*AT preventive measure $or motorcyclists and bicyclists. *ven subtle behavior changes, such as restlessness, irritability, or con$usion, may indicate increased #2%. 2S9 lea)age carries the ris) o$ meningitis and indicates a deteriorating condition. -ecause o$ 2S9 lea)age, the usual signs o$ increased #2% may not occur. Try not to use restraints> they only increase restlessness. A?&#D narcotics since they mas) level o$ responsiveness. %hysical assessment should concentrate on respiratory status, especially in clients with in1ury at 2AF to 2A5, as cervical plexus innervates diaphragm. #t is imperative to reverse spinal shoc) as <uic)ly as possible. %ermanent paralysis can occur i$ a spinal cord is compressed $or ,' to '4 hours. A common cause o$ death a$ter spinal cord in1ury is urinary tract in$ection. -acteria grow best in al)aline media, so )eeping urine diluted ad acidic is prophylactic against in$ection. Also, )eeping the bladder emptied assists in avoiding bacterial growth in urine, which is stagnated in the bladder. -enign tumors continue to grow and ta)e up space in the con$ined area o$ the cranium causing neural and vascular compromise $or the brain, increased intracranial pressure, and necrosis o$ brain tissue K even benign tumors must be treated as they may have malignant e$$ects. 2raniotomy postAoperative medications+ - 2orticosteroids to reduce swelling - Agents and osmotic diuretics to reduce secretions (atropine, robinul" - Agents to reduce sei@ures (phenytoin" - %rophylactic antibiotics Symptoms involving motor $unction usually begin in the upper extremities with wea)ness progressing to spastic paralysis. -owel and bladder dys$unction occurs in Q! o$ the cases. .S is more common in women. %rogression is not Iorderly.J Drug therapy $or .S clients+ A2T(, cortisone, 2ytoxan, and other immunosuppressive drugs. Cursing implications $or administration o$ these drugs should $ocus on prevention o$ in$ection. #n clients with .yasthenia 8ravis, be alert $or changes in respiratory status K the most severe involvement may result in respiratory $ailure. -edrest o$ten relieves symptoms. -ladder and respiratory in$ections are o$ten a recurring problem. Ceed $or health promotion teaching. .yasthenic crisis is associated with a positive edrophonium (Tensilon" test, while a cholinergic crisis is associated with a negative test. C2;*DARC <uestions o$ten $ocus on the $eatures o$ %ar)inson/s disease K tremors (a coarse tremor o$ $ingers and thumb on one hand which disappears during sleep and purpose$ul activity K also called Ipill rollingJ", rigidity, hypertonicity, and stooped posture. 9ocus+ SA9*TBO An important aspect o$ %ar)inson/s treatment is drug therapy. Since the pathophysiology involves an imbalance between acetylcholines and dopamine, symptoms can be controlled by administering dopamine precursor (;evodopa". 2CS involvement related to cause o$ 2?A+ - (emorrhagic+ caused by a slow or $ast hemorrhage into the brain tissue K o$ten related to hypertension. - *mbolytic+ caused by a clot, which has bro)en away $rom some vessel and has lodged in one o$ the arteries o$ the brain, bloc)ing the blood supply. #t is o$ten related to atherosclerosis (may happen again". Atrial $lutter0$ibrillation has a high incidence o$ thrombus $ormation $ollowing arrythmias due to turbulence o$ blood $low through all valves0heart chambers. A woman who had a stro)e two days ago has le$tAsided paralysis. She has begun to regain some movement in her le$t side. :hat can the nurse tell the $amily about the client/s recovery period= - The <uic)er movement is recovered, the better the prognosis is $or more or $ull recovery. She will need patience and understanding $rom her $amily as she tries to cope with the stro)e. .ood swings can be expected during the recovery period, and bouts o$ depression and tear$ulness are li)ely. :ords that describe losses $rom 2?A+ - Apraxia+ inability to per$orm purpose$ul movements in the absence o$ motor problems. - Dysarthria+ di$$iculty articulating - Dysphasia+ impairment o$ speech and verbal comprehension - Aphasia+ loss o$ the ability to spea) - Agraphia+ loss o$ the ability to write - Alexia+ loss o$ the ability to read - Dysphagia+ dys$unctional swallowing Steroids are administered a$ter a stro)e to decrease cerebral edema and retard permanent disability. (' inhibitors are administered to prevent peptic ulcers. HEMATOLOGY/ONCOLOGY %hysical symptoms occur as a compensatory mechanism when the body is trying to ma)e up $or a de$icit somewhere in the system. 9or instance, cardiac output increases when hemoglobin levels drop below Gg0dl. &C;B use normal saline to $lush #? tubing or to run with blood. C*?*R add medications to blood products. T:& registered nurses should simultaneously chec) the physician/s prescription, client/s identity, and blood bag label. A '4Ayear old is admitted with large areas o$ ecchymosis on both upper and lower extremities. She is diagnosed with acute myeologenous leu)emia. :hat are the expected laboratory $indings $or this client and what is the expected treatment= - ;ab+ Decreased (gb, decreased (ct, decreased platelet count, altered :-2 (usually <uite high". 11 - Treatment+ %revention o$ in$ection> prevention and0or control o$ bleeding> high protein, high calorie diet> assistance with AD;> drug therapy. #n$ection in the immunosuppressed person may not be mani$ested with an elevated temperature. #t is imperative, there$ore, that the nurse per$orms a total and thorough assessment o$ the client $re<uently. .ost oncologic drugs cause immunosuppression. %revention o$ secondary in$ections is vitalO Advise client to stay away $rom persons with )nown in$ections such as colds. #n the hospital, maintain an environment as sterile and as clean as possible. These persons should not eat raw vegetables or $ruits K only coo)ed to destroy any bacteria. (odg)in/s is one o$ the most curable o$ all adult malignancies. *motional support is vital. 2areer development is o$ten interrupted $or treatment. 2hemotherapy renders many male clients sterile. .ay ban) sperm prior to treatment, i$ desired. REPRODUCTIVE SYSTEM .enorrhagia (pro$use or prolonged menstrual bleeding" is the most important $actor relating to benign uterine tumors. Assess $or signs o$ anemia. :hat is the anatomical signi$icance o$ a prolapsed uterus= :hen the uterus is displaced, it impinges on other structures in the lower abdomen. The bladder, rectum, and small intestine can protrude through the vaginal wall. ;aser therapy or cryosurgery is used to treat cervical cancer when the lesion is small and locali@ed. #nvasive cancer is treated with radiation, coni@ation, hysterectomy, or pelvic exenteration (a drastic surgical procedure where the uterus, ovaries, $allopian tubes, vagina, rectum, and bladder are removed in an attempt to stop metastasis". 2hemotherapy is not use$ul with this type o$ cancer. %ap smears should begin within F years o$ having intercourse or no later than age ',, whichever comes $irst. Should be done annually until age F and then may be done every ' to F years i$ a woman has F consecutive normal results. A$ter age G may stop i$ woman has F consecutive normal and no abnormal pap smears in last , years. :omen at high ris) should have annual screenings. &varian cancer is the leading cause o$ death $rom gynecologic cancers in the 7S. 8rowth is insidious, so it is not recogni@ed until it is at an advanced stage. The ma1or emphasis in nursing management o$ cancers o$ the reproductive tract is early detection. The importance o$ teaching $emale clients how to do sel$A breast examination cannot be overemphasi@ed. *arly detection is related to positive outcomes. The presence or absence o$ hormone receptors is paramount in selecting clients $or ad1uvant therapy. .en whose testes have not descended into the scrotum or whose testes descended a$ter age 6 are at high ris) $or developing testicular cancer. The most common symptom is the appearance o$ a small, hard lump about the si@e o$ a pea on the $ront or side o$ the testicle. .anual testicular examination should be done a$ter a shower by gently palpating the testes and cord to loo) $or a small lump. Swelling may also be a sign o$ testicular cancer. STDs in in$ants and children usually indicate sexual abuse and should be reported. The nurse is legally responsible to report cases o$ child abuse. 2hlamydia is the most reported communicable disease in the 7nited States. %elvic in$lammatory disease (%#D" involves one more o$ the pelvic structures. The in$ection can cause adhesions and eventually result in sterility. .anage the pain associated with %#D with analgesics and warm sit@ baths. -edrest in a semiA9owler/s position may increase com$ort and promote drainage. Antibiotic treatment is necessary to reduce in$lammation and pain. A client comes to the clinic with a chancre on his penis. :hat is the usualy treatment= - #. dose o$ penicillin (such as -en@athine penicillin 8 '.4 million units". - &btain sexual history, including the names o$ his sex partners, so that they can receive treatment. BURNS .assive volumes o$ #? $luids are given. #t is not uncommon to give over ,, cc0hr during various phases o$ burn care. (emodynamic monitoring must be closely observed to be sure the client is supported with $luids but is not overloaded. #n$ection is a li$eAthreatening ris) $or those with burns. Dressing changes are ?*RB %A#C97;O .edicate client prior to procedure. %reAexisting conditions that might in$luence burn recovery are age, chronic illness, diabetes, cardiac problems, etc.", physical disabilities, disease, medications used routinely, and drug and0or alcohol abuse. PEDIATRIC NURSING GROWTH AND DEVELOPMENT: 1. When doe !"#$h %en&$h do'!%e( S by 4 years 2. When doe $he )h"%d "$ 'n'**o#$ed( S N months 3. When doe + )h"%d +)h"e,e -./ o0 +d'%$ he"&h$( S ' years 4. When doe + )h"%d $h#o1 + !+%% o,e#h+nd( S ,N months 5. When doe + )h"%d *e+2 345 1o#d en$en)e( S ' years 6. When doe + )h"%d 'e )"o#( S 4 years 7. When doe + )h"%d $"e h"/he# hoe( S 5 years -e aware that a girl/s growth spurt during adolescence begins earlier than boys (as early as , years old". Temper tantrums are common in the toddler, i.e., considered Inormal,J or average behavior. 12 -e aware that adolescence is a time when the child $orms his0her identity and that rebellion against $amily values is common $or this age group. Cormal growth and development )nowledge is used to evaluate interventions and therapy. 9or example, I:hat behavior would indicate that thyroid hormone therapy $or a 4A monthAold is e$$ective=J Bou must )now what milestones are accomplished by a 4AmonthAold. &ne correct answer would be Ihas steady head controlJ which is an expected milestone $or a 4AmonthAold and indicates that replacement therapy is ade<uate $or growth. 7se $acts and principles related to growth and development in planning teaching interventions. 9or example+ I:hat tas) could a 5AyearAold diabetic boy be expected to accomplish by himsel$=J &ne correct answer would be to pic) the in1ection sites. This is possible $or a preschooler to do and gives the child some sense o$ control. SchoolAage children are in *ri)son/s stage o$ industry, meaning they li)e to do and accomplish things. %eers are also becoming important $or this age child. Age groups concepts o$ bodily in1ury+ - #n$ants+ A$ter 6 months, their cognitive development allows them to remember pain. - Toddlers+ 9ear intrusive procedures. - %reschoolers+ 9ear body mutilation. - School Age+ 9ear loss o$ control o$ their body. - Adolescent+ .a1or concern is change in body image. CHILD HEALTH PROMOTION Subcutaneous in1ection, rather than intradermal, invalidates the .antoux test. The common cold is not a contraindication $or immuni@ation. 9ollowing immuni@ation, what teaching should the nurse provide to the parents= - #rritability, $ever (5,'9", redness and soreness at in1ection site $or ' to F days are normal side e$$ects o$ D%T and #%? administration. - 2all health care provider i$ sei@ures, high $ever, or highA pitched crying occur. - A warm washcloth on the thing in1ection site and IbicyclingJ the legs with each diaper change will decrease soreness. - Acetaminophen (Tylenol" is administered orally 4 to 6 hours (, to ,5 mg0Hg". 2hildren with 8erman measles pose a serious threat to their unborn siblings. The nurse should counsel all expectant mothers, especially those with young children, to be aware o$ the serious conse<uences o$ exposure to 8erman measles during pregnancy. 2ommon childhood problems are encountered by nurses caring $or children in the community or hospital settings. The child/s age directly in$luences the severity and management o$ these problems. Teach proper coo)ing and storage to preserve potency, i.e., coo) vegetables in small amount o$ li<uid. Store mil) in opa<ue container. Add potassium to #? $luids &C;B with ade<uate urine output. 7rinary output $or in$ants and children should be , to ' ml0)g0hr. 7se o$ syrup o$ ipecac is no longer recommended by the American Academy o$ %ediatrics. Teach parents that it is C&T recommended to induce vomiting in any way as it may cause more damage. RESPIRATORY DISORDERS 2hild needs ,5! o$ the usual calorie inta)e $or normal growth and development. Do not examine the throat o$ a child with epiglottis due to the ris) o$ completely obstructing the airway, i.e., do not put a tongue blade or any ob1ect in the throat. #n planning and providing nursing care, a patent airway is always a priority o$ care, regardless o$ ageO Respiratory disorders are the primary reason most children and their $amilies see) medical care. There$ore, these disorders are $re<uently tested on the C2;*DARC. Hnowing the normal parameters $or respiratory rates and the )ey signs o$ respiratory distress in children is essentialO The nurse should be sure a %T and %TT have been determined prior to a tonsillectomy. .ore importantly, the nurse should as) i$ there has been a history o$ bleeding, prolonged0excessive, or i$ there is a history o$ any bleeding disorders in the $amily. :hen calculating a pediatric dosage, the nurse must o$ten change the child/s weight $rom pounds to )ilograms. (#CT+ weight expressed in )ilograms should always be a smaller number than weight expressed in pounds. CARDIOVASCULAR DISORDERS %olycythemia is common in children with cyanotic de$ects. The heart rate o$ a child will increase with crying or $ever. #n$ants may re<uire tube $eeding to conserve energy. -asic di$$erence between cyanotic and acyanotic de$ects+ - Acyanotic+ (as abnormal circulation, however, all blood entering the systemic ciruclation is oxygenated. - 2yanotic+ (as abnormal circulation with unoxygenated blood entering systemic circulation. 2ongestive heart $ailure is more o$ten associated with acyanotic de$ects. 2(9 is a common complication o$ congenital heart disease. #t re$lects the increased wor)load o$ the heart resulting $rom 13 shunts or obstructions. The two ob1ectives in treating 2(9 are to reduce the wor)load o$ the heart and increase cardiac output. :hen $re<uent weighings are re<uired, weigh client on the same scale at same time o$ day so that accurate comparisons can be made. NEUROMUSCULAR DISORDERS The nursing goal in caring $or children with Down syndrome is to help the child reach his0her &%T#.A; level o$ $unctioning. 9eed in$ant or child with cerebral palsy using nursing interventions aimed at preventing aspiration. %osition child upright and support the lower 1aw. The signs o$ #2% are the opposite o$ those o$ shoc). - Shoc)+ #ncreased pulse, Decreased blood pressure. - #ncreased #2%+ Decreased pulse, #ncreased blood pressure. -aseline data on the child/s 7S7A; behavior and level o$ development is essential so changes associated with increased #2% can be detected *AR;B. Do not pump shunt unless speci$ically prescribed. The shunt is made up o$ delicate valves, and pumping changes pressures within the ventricles. .edication noncompliance is the most common cause o$ increased sei@ure activity. Do C&T use tongue blade, padded or not, during a sei@ure. #t can cause traumatic damage to mouth0oral cavity. .onitor hydration status and #? therapy care$ully. :ith meningitis, there may be inappropriate AD( secretions causing $luid retention (cerebral edema" and dilutional hyponatremia. (eadache upon awa)ening is the most presenting symptom o$ brain tumors. .ost postoperative clients with in$ratentorial tumors are prescribed to lie $lat and turn to either side. A large tumor may re<uire that the child C&T be turned to the operative side. Suctioning, coughing, straining, and0or causes increased #2%. RENAL DISORDERS Decreased urinary output is 9#RST sign o$ renal $ailure. Surgical correction $or hypospadias is usually done be$ore preschool years due to achieving sexual identity, castration anxiety and toilet training. GASTROINTESTINAL DISORDERS Typical parent0$amily reaction to a child with an obvious mal$ormation such as cle$t lip0palate are <uilt, disappointment, grie$, sense o$ loss, and anger. 2hildren with cle$t lip0palate and those with pyloric stenosis both have a nursing diagnosis Ialteration in nutrition> less than body re<uirements.J - 2le$t lip0palate is related to decreased ability to suc). - %yloric stenosis is related to $re<uent vomiting. Cutritional needs and $luid and electrolyte balance are )ey problems $or children with 8# disorders. The younger the child, the more vulnerable they are to $luid and electrolyte imbalances and greater is the need $or caloric inta)e re<uired $or growth. Ta)e axillary temperature on children with congenital megacolon. HEMATOLOGICAL DISORDERS Remember the (gb norms+ - Cewborn+ ,4 to '4 g0dl - #n$ant+ , to ,5 g0dl - 2hild+ ,, to ,6 g0dl Teach $amily about administration o$ oral iron+ - 8ive on empty stomach (as tolerated $or better absorption" - 8ive with citrus 1uices (vitamin 2" $or increased absorption - 7se dropper or straw to avoid discoloring teeth - Stools will become tarry - #ron can be $atal in severe overdose> )eep away $rom children. Do not give with dairy products. #nherited bleeding disorders (hemophilia and sic)le cell anemia" are o$ten used to test )nowledge o$ genetic transmission patterns. Remember+ - Autosomal recessive+ -oth parents must be hetero@ygous, or carriers o$ the recessive trait, $or the disease to be expressed in their o$$spring. :ith each pregnancy, there is a ,+4 chance o$ the in$ant having the disease. (owever, all children o$ such patterns 2AC get the disease K C&T '5! o$ them. This is the transmission $or sic)le cell anemia, cystic $ibrosis, and phenyl)etonuria (%H7". - DAlin)ed recessive trait+ The trait is carried on the D chromosome, there$ore, usually a$$ects male o$$spring, e.g., hemophilia. :ith each pregnancy o$ a woman who is a carrier there is a '5! chance o$ having a child with hemophilia. #$ the child is male, he has a 5! chance o$ having hemophilia. #$ the child is $emale, she has a 5! chance o$ being a carrier. (ydration is very important in treatment o$ sic)le cell disease because it promotes hemodilution and circulation o$ red cells through the blood vessels. #mportant terms+ - (etero@ygous gene ((gbAS" sic)le cell trait - (omo@ygous gene ((bSS" sic)le cell disease - Abnormal hemoglobin ((8-S" disease and trait Supplemental iron is not given to clients with sic)le cell anemia. The anemia is not caused by iron de$iciency. 9olic acid is given only to stimulate R-2 synthesis. (ave epinephrine and oxygen readily available to treat anaphylaxis when administering lAasparaginase. 14 %rednisone is $re<uently used in combination with antineoplastic drugs to reduce the mitosis o$ lymphocytes. Allopurinol, a xanthineAoxidase inhibitor, is also administered to prevent renal damage $rom uric acid build up during cellular lysis. METABOLIC AND ENDOCRINE DISORDERS An in$ant with hypothyroidism is o$ten described as a Igood, <uiet babyJ by the parents. *arly detection o$ hypothyroidism and phenylhetonuria is essential in preventing mental retardation in in$ants. Hnowledge o$ normal growth and development is important, since a lac) o$ attaintment can be used to detect the existence o$ these metabolic0endocrine disorders and attainment can be used $or evaluating the treatment/s e$$ect. Cutrasweet (aspartame" contains phenylalanine and should not there$ore, be given to a child with phenyl)etonuria. Diabetes mellitus (D." in children was typically diagnosed as insulin dependent diabetes (Type #" until recently. A mar)ed increase in Type ## D. has occurred recently in the 7S, particularly among CativeAAmerican, A$ricanAAmerican, and (ispanic children and adolescents. Adolescence $re<uently causes di$$iculty with management since growth is rapid and the need to be li)e peers ma)es compliance di$$icult. Remember to consider the child/s age, cognitive level o$ development, and psychosocial development when answering C2;*DARC <uestions. :hen child is in )etoacidosis, administer regular insulin #? as prescribed in normal saline. There has been an increase in the number o$ children diagnosed with Type ## diabetes. The increasing rate o$ obesity in children is thought to be a contributing $actor. &ther contributing $actors include lac) o$ physical activity and a $amily history o$ Type ## diabetes. SKELETAL DISORDERS 9ractures in older children are common as they $all during play and are involved in motor vehicle accidents. Spiral $ractures (caused by twisting" and $ractures in in$ants may be related to child abuse. 9ractures involving the epiphyseal plate (growth plate" can have serious conse<uences in terms o$ growth o$ the a$$ected limb. S)in traction $or $racture reduction should not be removed unless prescribed by healthcare provider. %in sites can be sources o$ in$ection. .onitor signs o$ in$ection. 2leanse and dress pin sites as prescribed. S)eletal disorders a$$ect the in$ant/s or child/s physical mobility, and typical C2;*DARC <uestions $ocus on appropriate toys or activities $or the child who is on bedrest and0or immobili@ed. 2hildren do not li)e in1ections and will deny pain to avoid Ishots.J A brace does not correct the curve o$ a child with scoliosis, it only stops or slows the progression. 2orticosteroids are used short term in low doses during exacerbations. ;ongAterm use is avoided due to side e$$ects and their adverse e$$ect on growth. MATERNITY NURSING ANATOMY 6 PHYSIOLOGY O7 REPRODUCTION The menstrual phase varies in length $or most women. 9rom ovulation to the beginning o$ the next menstrual cycle is usually exactly ,4 days. #n other words, ovulation occurs ,4 days be$ore the next menstrual period. Sperm lives approximately F days and eggs live about '4 hours. A couple must avoid unprotected intercourse $or several days be$ore the anticipated ovulation and $or F days a$ter ovulation in order to prevent pregnancy. -ecause some women experience implantation bleeding or spotting, they do not )now they are pregnant. ;oo) $or signs o$ maternalA$etal bonding during pregnancy. 9or example+ tal)ing to $etus in utero, massaging abdomen, nic)naming $etus are all healthy psychosocial activities. 9or many women, -ATT*R#C8 (emotional or physical abuse" begins during pregnancy. :omen should be assessed $or abuse in private, away $rom the male partner, by a nurse who )nows local resources and how to determine the sa$ety o$ the client. %ractice determining gravidity and parity+ A woman who is 6 wee)s pregnant has the $ollowing maternal history+ - (as a ' yr. old healthy daughter. - (ad a miscarriage at , wee)s, F years ago. - (ad an elective abortion at 6 wee)s, 5 years ago. :ith this pregnancy, she is a gravida 4, para , (only , delivery a$ter ' wee)s gestation". %ractice calculating *D- (estimated date o$ birth". #$ the $irst day o$ a women/s last normal menstrual period was &ctober ,G, what is her *D- using Cagele/s rule= Ruly '4. 2ount bac) F months and add G days (always give 9ebruary 'N days". At approximately 'N to F' wee)s gestation, the maximum plasma volume increase o$ '5 to 4! occurs, resulting in normal hemodilution o$ pregnancy and (ct values o$ F' to 4'!. (igh (ct values may loo) Igood,J but in reality represent pregnancyAinduced hypertension and a depleted vascular space. (gb0(ct data can be used to evaluate nutritional status. *xample+ a ''Ayear old primigravida at ,' wee)s gestation has a high (gb o$ Q.6 g0dl and a (ct o$ F,!. She has gained F pounds during the $irst trimester. A weight gain o$F.5 to 5 pounds during the $irst trimester is recommended 15 and this client is anemic. Supplemental iron and a diet higher in iron are needed. 9oods high in iron+ $ish and red meats> cereal and yellow vegetables> green lea$y vegetables and citrus $ruits> egg yol)s and dried $ruits. As pregnancy advances, the uterus presses on abdominal vessels (vena cava and aorta". Teach the woman that a sideA lying position increases per$usion to uterus, placenta, and $etus. Recent research indicates that the )neeAchest position is best $or increasing per$usion and that the sideAlying position (either le$t or right sideAlying" is the second most desirable position to increase per$usion. %rior to this research, the le$t sideAlying position was usually encouraged. 9etal wellAbeing is determined by assessing $undal height, $etal heart tones0rate, $etal movement and uterine activity (contractions". 2hanges in $etal heart rate are the $irst and most important indicator o$ compromised blood $low to the $etus, and these changes re<uire actionO Remember, the normal 9(R is ,, to ,6 bpm. Danger signs during pregnancy. Teach clients to immediately report any o$ the $ollowing danger signs. *arly intervention can optimi@e maternal and $etal outcome. %ossible indications o$ preeclampsia0eclampsia+ - ?isual disturbances - Swelling o$ $ace, $ingers or sacrum - Severe, continuous headache - %ersistent vomiting Signs o$ in$ection+ - 2hills - Dysuria - Temperature over ,.4 9 - %ain in abdomen - 9luid discharge $rom vagina (anything other than normal leu)orrhea" - 2hange in $etal movement and0or increased 9(R .ost providers prescribe prenatal vitamins to ensure that the client receives an ade<uate inta)e o$ vitamins. (owever, only the healthcare provider can prescribe prenatal vitamins. #t is the nurse/s responsibility to teach about proper diet and ta)ing prescribed vitamins, i$ prescribed by the healthcare provider. #t is recommended that pregnant women drin) one <uart o$ mil)0day. This will ensure that the daily calcium needs are met an help to alleviate the occurrence o$ leg cramps. 7ETAL/MATERNAL ASSESSMENT TECHNI8UES #n some states, the screening $or neural tube de$ects through either maternal serum A9% levels or amniotic $luid A9% levels is mandated by state law. This screening test is highly associated with both $alse positives and $alse negatives. :hen an amniocentesis is done in early pregnancy, the bladder must be $ull to help support the uterus and to help push the uterus up in the abdomen $or easy access. :hen an amniocentesis is done in late pregnancy, the bladder must be empty to avoid puncturing the bladder. *arly decelerations, caused by head compression and $etal descent, usually occur between 4 and G cm and in the ' nd stage. 2hec) $or labor progress i$ early decelerations are noted. #$ cord prolapse is detected, the examiner should position the mother to relieve pressure on the cord (i.e., )neeAchest position" or push the presenting part o$$ the cord until #..*D#AT* 2esarean delivery can be accomplished. ;ate decelerations indicate uteroplacental insu$$iciency and are associated with conditions such as postmaturity, preeclampsia, diabetes mellitus, cardiac disease, and abruptio placentae. :hen deceleration patterns (late or variable" are associated with decreased or absent variability and tachycardia, the situation is &.#C&7S (potentially disastrous" and re<uires immediate intervention and $etal assessment. A decrease in uteroplacental per$usion results in late decelerations> cord compression results in a pattern o$ variable decelerations. Cursing interventions should include changing maternal position, discontinuing %itocin in$usion, administering oxygen and noti$ying the healthcare provider. The danger o$ nipple stimulation lies in controlling the IdoseJ o$ oxytocin stimulated $rom the posterior pituitary. The chance o$ hyperAstimulation or tetany (contractions over Q seconds or contractions with less than F seconds in between" is increased. %ercutaneous umbilical blood sampling (%7-S" can be done during pregnancy under ultrasound $or prenatal diagnosis and therapy. (emoglobinopathies, clotting disorders, sepsis, and some genetic testing can be done using this method. The most important determinant o$ $etal maturity $or extraA uterine survival is the ;0S ratio ('+, or higher". INTRAPARTUM NURSING CARE -e able to di$$erentiate true labor $rom $alse labor. True labor+ - %ain in lower bac) that radiates to abdomen - Accompanied by regular, rhythmic contractions - 2ontractions that intensi$y with ambulation - %rogressive cervical dilation and e$$acement 9alse labor+ - Discom$ort is locali@ed in abdomen - Co lower bac) pain - 2ontractions decrease in intensity and0or $re<uency with ambulation Hnow normal $indings $or clients in labor+ - Cormal 9(R in labor+ ,, to ,6 bpm - Cormal maternal -%+ 5,40Q - Cormal maternal pulse+ 5, bpm - Cormal maternal temperature+ 5,.4 9 16 Slight elevation is o$ten due to dehydration and the wor) o$ labor. Anything higher indicates in$ection and must be reported immediately. Admission procedures+ - vulvar0perineal shave (may not be done" - enema+ may be re$used by woman due to preAlabor diarrhea or recent, large bowel movement. An enema should not be administered to a client in active labor. #$ head is $loating, watch $or cord prolapse. .econiumAstained $luid is yellowAgreen and may indicate $etal stress. -reathing techni<ues such as deep chest, accelerated, and cued are not prescribed by the stage and phase o$ labor, but by the discom$ort level o$ the laboring woman. #$ coping is decreasing, switch to a new techni<ue. (yperventilation results in respiratory al)alosis due to blowing o$$ too much 2&'. Symptoms include+ - Di@@iness - Tingling o$ $ingers - Sti$$ mouth - (ave woman breathe into her cupped hands or a paper bag in order to rebreathe 2&'. Determine cervical dilation be$ore allowing client to push. 2ervix should be completely dilated (, cm" be$ore the client begins pushing. #$ pushing starts too early, the cervix can become edematous and never $ully dilate. 8ive the oxytocin a$ter the placenta is delivered because the drug will cause the uterus to contract. #$ the oxytocic drug is administered be$ore the placenta is delivered, it may result in a retained placenta, which predisposes the client to hemorrhage and in$ection. Application o$ perineal pads a$ter delivery+ - %lace two on perineum - Do C&T touch inside o$ pad - D& apply $rom $ront to bac), being care$ul not to drag pad across the anus. .ethergine is C&T given to clients with hypertension due to its vasoconstrictive action. %itocin is given with caution to those with hypertension. 97;; -;ADD*R is one o$ the most common reasons $or uterine atony and0or hemorrhage in the $irst '4 hours a$ter delivery. #$ the nurse $inds the $undus so$t, boggy, and displaced above and to the right o$ the umbilicus, what action should be ta)en $irst= 9irst, per$orm $undal massage> then have the client empty her bladder. Rechec) $undus <,5 minutes D 4 (, hour"> <F minutes D ' hours. #$ narcotic analgesics (codeine, meperidine" are given, raise side rails and place call light within reach. #nstruct client not to get out o$ bed or ambulate without assistance. 2aution client about drowsiness as a side e$$ect. A , st degree tear involves only the epidermis. A ' nd degree tear involves dermis, muscle, and $ascia. A F rd degree tear extends into the anal sphincter, and a 4 th degree extends up the rectal mucosa. Tears cause pain and swelling. Avoid rectal manipulations. #$ it was documented that the $etus passed meconium in utero or the nurse noted ;AT* passage o$ meconium in delivery room, the neonate .7ST be attended by a pediatrician, neonatologist, and0or nurse practitioner to determine, through endotracheal tube observation and suction, the presence o$ meconium below the cords. #t can result in pneumonitis0meconium aspiration syndrome, which will necessitate a sepsis wor)up including a chest xAray early in the transitional newborn period. Do not wait until a , minute Apgar is assigned to begin resuscitation o$ the compromised neonate. Apgar scores o$ 6 or 5 at 5 minutes re<uire an additional Apgar assessment at , minutes. #? administration o$ analgesics is pre$erred to #. $or the client in labor because the onset and pea) occurs more <uic)ly and duration o$ the drug is shorter.
#? administration+ - %redictable onset+ 5 minutes - %ea)+ F minutes - Duration+ , hour #. administration+ - &nset+ within F minutes - %ea)+ , to F hours a$ter in1ection - Duration+ 4 to 6 hours Tran<uili@ers (ataractics and0or phenothia@ines" %henergan, ?istaril, are used in labor as analgesicApotentiating drugs to decrease maternal anxiety. Agonist narcotic drugs (Demerol, morphine" produce narcosis and have a higher ris) $or maternal0$etal respiratory depression. Antagonist drugs (Stadol, Cubain" have less respiratory depression but .7ST be used with caution in a mother with preexisting narcotic dependency since withdrawal symptoms occur immediately. %udendal bloc) and subarachnoid (saddle bloc)" are used only $or second stage o$ labor. %eri0epidural may be used $or all stages o$ labor. The $irst sign o$ bloc) e$$ectiveness is usually warmth and tingling o$ ball0big toe o$ $oot. Discontinue continuous in$usion at end o$ Stage # or during transition to increase pushing e$$ectiveness. Regional bloc) anesthesia and $etal presentation - #nternal rotation is harder to achieve when the pelvic $loor is relaxed by anesthesia resulting in persistent occiput posterior position o$ $etus. - .onitor $or $etal position. R*.*.-*R, mother cannot tell you she has bac) pain, which is the cardinal sign o$ persistent posterior $etal position. - Regional bloc)s, especially epidural and caudal, o$ten result in assisted ($orceps or vacuum" delivery due to the inability to push e$$ectively in ' nd stage. 17 Cerve bloc) anesthesia (spinal or epidural" during labor bloc)s motor as well as nerve $ibers. ?asodilation below the level o$ the bloc) results in blood pooling in the lower extemities and maternal hypotension. Approximately ' minutes prior to nerve bloc) anesthesia, the client should be hydrated with 5 to , cc o$ lactated ringers #?. .onitor maternal vital signs and 9(R <5 to ,5 minutes. #$ hypotension occurs K turn the client to her side, administer &' at , ;0min by $acemas), and increase #? rate. NORMAL PUERPERIUM Cormal leu)ocytosis o$ pregnancy averages ,', to ,5, mmF. The $irst , to ,' days postAdelivery, values o$ '5, mmF are common. *levated :-2 and the normal elevated *SR may con$use interpretation o$ acute postpartal in$ections. 9or example, i$ the nurse assesses a client/s temperature to be ,, 9 on the client/s second postpartum day, what assessments should be made be$ore noti$ying the physician= Assess $undal height and $irmness, perineal integrity, chec) $or a positive (oman/s sign and other symptoms, i.e., burning on urination, pain in leg, excessive tenderness o$ uterus. 2lient0$amily teaching is a common area $or C2;*DARC <uestions. Remember, when teaching the $irst step is to assess the client/s (parent/s" level o$ )nowledge and identi$y their readiness to learn. 2lient teaching regarding lochia changes, perineal care, breast$eeding, sore nipples are commonly tested content. A$ter the , st %% day, the most common cause o$ uterine atony is retained placental $ragments. The nurse must chec) $or presence o$ $ragments in lochial tissue. :omen can tolerate blood loss, even slightly excessive blood loss, in the postpartal period due to the 4! increase in plasma volume during pregnancy. #n postpartal period can void up to F, cc0day to reduce this volume increase that occurred during pregnancy. 2lient should void within 4 hours o$ delivery. .onitor closely $or urine retention. Suspect retention i$ voiding is $re<uent and 5, cc per voiding. :omen o$ten have a syncopal spell ($aint" on the $irst ambulation a$ter delivery (usually related t ovasomotor changes, orthostatic hypotension". The astute nurse will chec) $or client/s (gb and (ct $or anemia and the blood pressure, sitting and lying $or orthostatic hypotension. Hegel exercises+ increase integrity o$ introitus and improve urine retention. Teach client to alternate contraction and relaxation o$ the pubococcygeal muscles. Assess $or thromboembolism+ *xamine legs o$ %% client daily $or pain, warmth, and tenderness or a swollen vein which is tender to touch. 2lient may or may not exhibit a positive (oman/s sign (dorsi$lexion o$ $oot causes compression o$ tibial veins and pain i$ thrombus is present". I%ostpartum bluesJ are usually normal, especially 5 to G days a$ter delivery (unexplained tear$ulness, $eeling Idown,J and a decreased appetite". *ncourage use o$ support persons to help with housewor) $or $irst two postpartum wee)s. Re$er to community resources. Remember Rho8A. is given to a RhAnegative mother who delivers a RhApositive $etus and has a negative direct 2oombs. #$ the mother has a positive 2oombs, there is no need to give Rho8A. since the mother is already sensiti@ed. -ecause Rh #mmune 8lobulins suppress the immune system, the client who receives both Rho8A. and the Rubella vaccine should be tested $or rubella immunity at F months. THE NORMAL NEWBORN %(BS#2A; ASS*SS.*CT+ A detailed physical assessment is per$ormed by the nurse or physician. Regardless o$ who per$orms the physical assessment, the nurse must )now normal versus abnormal variations o$ the newborn. &bservations must be recorded and the physician and the physician noti$ied regarding abnormalities. #t is di$$icult to di$$erentiate between caput succedaneum (edema under the scalp" and cephalhematoma (blood under the periosteum". The caput crosses suture lines and is usually present at birth, while the cephalhematoma does C&T cross suture lines and mani$ests a $ew hours a$ter birth. The danger o$ cephalhematoma is increased by hyperbilirubinemia due to excess R-2 brea)down. These neurological re$lexes are transient, and, as such, disappear usually within the $irst year o$ li$e. #n the pediatric client, prolonged presence o$ these re$lexes can indicate 2CS de$ects. Anticipate C2;*DARC <uestions regarding normal newborn re$lexes. %hysical assessment <uestions $ocus on normal characteristics o$ the newborn and the di$$erentiation o$ conditions such as caput succedaneum and cephalhematoma. The umbilical cord should always be chec)ed at birth. #t should contain F vessels, , vein which carries oxygenated blood to the $etus and ' arteries which carry unoxygenated blood bac) to the placenta. This is the opposite o$ normal circulation in the adult. 2ord abnormalities usually indicate cardiovascular or renal anomalies. %ostnatally, the $etal structures o$ $oramen ovale, ductus arteriosus and ductus venosus should close. #$ they do not, cardiac and pulmonary compromise will develop. Suctioning the mouth $irst and then the nose. Stimulating the nares can initiate inspiration which could cause aspiration o$ mucus in oral pharynx. 2ircumcision has become controversial since there is no real medical indication $or the procedure and it does not cause trauma and pain to the newborn. #t was once thought to decrease the incidence o$ penile and cervical cancer, but some researchers say this is un$ounded. (B%&T(*R.#A (heat loss" leads to depletion o$ glucose and, there$ore, the use o$ brown $at (special $at deposits $etus puts on in last trimester which are important to thermoregulation" $or energy, resulting in )etoacidosis and possible shoc). %revent by )eeping neonate warmO 18 %hysiologic 1aundice (normal inability o$ the immature liver to )eep up with normal R-2 destruction" occurs at ' to F days o$ li$e. #$ it occurs be$ore '4 hours or persists beyond G days, it becomes pathologic. Typically, C2;*DARC <uestions as) about normal problem o$ physiologic 1aundice which occurs ' to F days a$ter birth due to the liver/s inability to )eep up with R-2 destruction and bind bilirubin. Remember, uncon1ugated bilirubin is the culprit. Do not $eed a newborn when the respiratory rate is over 6. #n$orm the physician and anticipate gavage $eedings in order to prevent $urther energy utili@ation and possible aspiration. A G lb. N o@. baby would need 5 calories D G lbs S F5 calories plus '5 calories (,0' lb. or N o@." S FG5 calories per day. .ost in$ant $ormulas contain ' calories0ounce. Dividing FG5 by ' S ,N.G5 ounces o$ $ormula needed per day. Teach parents to ta)e in$ant/s temperature -&T( axillary and rectally. :hile axillary is recommended, some pediatricians will re<uest a rectal temperature (core". - AD#;;ARB+ %lace thermometer under arm and hold thermometer in place 5 minutes. - R*2TA;;B+ 7se thermometer with -;7CT end. #nsert thermometer T to M inch and hold in place $or 5 minutes. (old $eet and legs $irmly. HIGH4RISK DISORDERS 2lients with prior traumatic delivery, history o$ DU2, multiple abortions (spontaneous or induced", or daughters o$ D*S mothers may experience miscarriage or preterm labor related to #C2&.%*T*CT 2*R?#D. The cervix may be surgically repaired prior to pregnancy, or D7R#C8 gestation. A 2*R2;A8* (.cDonald/s suture" is placed around the cervix to constrict the internal os. The cerclage may be removed prior to labor i$ labor is planned or le$t in place i$ cesarean birth is planned. Suspect ectopic pregnancy in any woman o$ childbearing age who presents at an emergency room, clinic, or o$$ice with unilateral or bilateral abdominal pain. .ost are misdiagnosed with appendicitis. A client who is F' wee)s gestation calls the healthcare provider because she is experiencing dar), red vaginal bleeding. She is admitted to the emergency room where the nurse determines the 9(R to be , bpm. The client/s abdomen is rigid and boardli)e, and she is complaining o$ severe pain. :hat action should the nurse ta)e $irst= 9irst, the nurse must use )nowledge base to di$$erentiate between abruptio placentae (this client" $rom placenta previa (painless bright red bleeding occurring in the third trimester". The nurse should immediately noti$y the healthcare provider and no abdominal or vaginal manipulation or exams should be done. Administer &' per $ace mas). .onitor $or bleeding at #? sites and gums due to the increased ris) o$ D#2. *mergency 2esarean section is re<uired since uteroplacental per$usion to the $etus is being compromised by early separation o$ the placenta $rom the uterus. 2lients with abruptio placentae or placenta previa (actual or suspected" should have C& abdominal or vaginal manipulation. C& ;eopold/s maneuvers. C& vaginal exams. C& rectal exams, enemas, or suppositories. C& internal monitoring. Disseminated intravascular coagulation (D#2" is a syndrome o$ abnormal clotting that is systematic and pathologic. ;arge amounts o$ clotting $actors, especially $ibrinogen, are depleted causing widespread external and0or internal bleeding. D#2 is related to $etal demise, in$ection0sepsis, pregnancyAinduced hypertension (%reeclampsia" and abruptio palcentae. %odophyllin, which is usually used to treat (%?, is contraindicated in pregnancy because it is associated with $etal death, preterm labor, and cervical carcinoma. Toxoplasmosis is usually related to exposure to cats, gardening (where cat $eces may be $ound", or eating raw meat. Rubella is teratogenic to the $etus during the 9#RST trimester, causing congenital heart disease and0or congenital cataracts. All women should have their titers chec)ed during pregnancy. #$ a women/s titer/s are low, she should receive the vaccine A9T*R delivery and be instructed not to get pregnant within F months. -reast$eeding mothers may ta)e the vaccine. Although .etronida@ole (9lagyl" is the treatment o$ choice $or some vaginal in$ections, its use is contraindicated in the $irst trimester o$ pregnancy, and its use during the second trimester is controversial. .edications usually recommended $or the nonApregnant client with STDs may be 2&CTRA#CD#2AT*D $or the pregnant client due to e$$ect on the $etus. The outcome o$ adolescent pregnancy depends on prenatal care. C7TR#T#&C is a )ey $actor since the adolescent/s physiological needs $or growth are already increased, plus the additional stress o$ pregnancy. Although the toxic side e$$ects o$ magnesium sul$ate are well )nown and watched $or, it is 1ust as important to get serum blood levels o$ magnesium sul$ate above 4 mg0dl in order to prevent convulsions and reach therapeutic range. (old next dose o$ magnesium sul$ate and noti$y healthcare provider i$ any toxic symptoms occur (5,' respirations0minute, urine output 5, cc04 hours, absent DTRs, .agnesium sul$ate 3 N mg0dl". :hen administering magnesium sul$ate. A;:ABS have antidote available (calcium gluconate, ' ml vial o$ ,! solution". Tachycardia is the ma1or sideAe$$ect o$ tocolytic drugs, which are bete adrenergic agents such as terbutaline (-rethine" or ritodrine (Butopar" used to stop preterm labor. Teach the client to ta)e her pulse prior to administration and withhold medication i$ pulse is not within the prescribed parameters (usually whitheld i$ pulse 3,' to ,4". #$ administration is via a continuous pump, teach client to monitor pulse periodically. 19 #n ,QGN, the 9DA banned the use o$ oxytocin $or *;*2T#?* inductions. The healthcare provider must provide, $or the record, the medical reason $or oxytocin use. Dystocia $re<uently re<uires the use o$ oxytocin $or augmentation or induction o$ labor. 7terine tetany is a harm$ul complication and care$ul monitoring is re<uired. The desired e$$ect is contractions <' to F minutes, with duration o$ contractions no longer than Q seconds. 2ontinuously monitor 9(R and uterine resting tone. #$ tetany occurs, turn o$$ %itocin, turn client to a sideAlying position, and administer &' by $acemas). 2hec) output (should be at least , cc04 hours". &xytocin/s most important side e$$ects is its antidiuretic (AD(" e$$ect, which can cause water intoxi$ication. 7sing #? $luids containing electrolytes decreases the ris) o$ water intoxi$ication. The uterus is most sensitive to becoming tetanic at the beginning o$ in$usion. The client must A;:ABS be attended and contractions monitored. 2ontractions should last C& longer than Q seconds to prevent $etal hypoxia. :omen with previous uterine scars are prone to uterine rupture especially i$ oxytocin or $orceps are used. #$ a woman complains o$ a sharp pain accompanied by the abrupt cessation o$ contractions, suspect uterine rupture, a .*D#2A; *.*R8*C2B. #mmediate surgical delivery is indicated to save the $etus and the mother. Rarely are antihypertensive drugs used in the preeclamptic client. They are given only in the event o$ diastolic blood pressure over ,, mm(g. (2?A danger". Drug o$ choice is (ydrala@ine (2; (Apresoline". Altough delivery is o$ten described as the IcureJ $or preeclampsia, the client can convulse up to 4N hours a$ter delivery. The ma1or goal o$ nursing care $or a client with preeclampsia is to maintain uteroplacental per$usion and prevent sei@ures. This re<uires the administration o$ magnesium sul$ate. :ithhold administration o$ magnesium sul$ate i$ signs o$ toxicity exist+ respirations 5,'0minute, absence o$ DTRs, and urine output 5F ml0hour. Cursing care during labor and delivery $or the client with cardiac disease is $ocused on prevention o$ cardiac embarrassment, maintenance o$ uterine per$usion, and alleviation o$ anxiety. Should these clients experience preterm labor, the use o$ betaAadrenergic agents such as terbutaline (-rethine" and ritodrine (2; (Butopar" are contraindicated due to the chance o$ myocardial ischemia. Cormal diuresis, which occurs in the postpartum period, can pose serious problems to the new mother with cardiac disease because o$ the increased cardiac output. 2oumadin may C&T be ta)en during pregnancy due to its ability to cross the placenta and a$$ect the $etus. (*%AR#C is the drug o$ choice> it does C&T cross the placental membrane. Recent research has $ound that (elicobacter pylori, (the bacterium that causes stomach ulcers" in$ection is another possible causative $actor in hyperemesis. &ther pregnancy and nonApregnancy ris) $actors $or hyperemesis gravidarum include $irst pregnancy, multiple $etuses, age under '4, history o$ this condition in other pregnancies, obesity, and high $at diets. #n severe cases o$ hyperemesis gravidarum, the healthcare provider may prescribe antihistamines, vitamin -6, or phenothia@ines to relieve nausea. The provider also prescribe metoclopramide (Reglan" to increase the rate the stomach moves $ood into the intestines, or antacids to absorb stomach acid and help prevent acid re$lux. :omen who su$$er $rom hyperemesis gravidarum are o$ten de$icient in thiamin, ribo$lavin, vitamin -6, vitamin A, and retinolAbinding proteins. 8;72&S* S2R**C+ 2lient does C&T have to $ast $or this test. 5 gm o$ glucose is given and blood is drawn a$ter one hour. #$ the blood glucose is greater than ,F5 mg0dl, the na threeAhour glucose tolerance test (8TT" is done. (igh incidence o$ $etal anomalies occurs in pregnant diabetic women. There$ore, $etal surveillance is very important. 7ltrasound exam. AlphaA$etoprotein (to determine neural tube anomalies". ConAstress and contraction stress tests. &ral hypoglycemics are not ta)en in pregnancy due to potential teratogenic e$$ects on $etus. #nsulin is used $or therapeutic management. :hen a woman is admitted in labor with diagnosis o$ diabetes mellitus. She is more prone to preeclampsia, hemorrhage and in$ection. Delivery is o$ten scheduled between FG to FN wee)s gestation to avoid the end o$ the F rd trimester o$ pregnancy because this is a ?*RB di$$icult time to maintain diabetic control. #t is use$ul to discontinue longAacting insulin administration on the day be$ore the delivery is planned since insulin re<uirements are less in labor and drop precipitously a$ter delivery. *strogenAcontaining birth control pills a$$ect glucose metabolism by increasing resistance to insulin. The intrauterine device may be associated with an increased ris) o$ in$ection in these already vulnerable women. #$ a woman is medicated, the responsible adult accompanying her must sign the necessary consent $orms. State laws di$$er as to the acceptability o$ a $riend signing the consent $orm rather than a relative. -abies delivered abdominally miss out on the vaginal s<uee@e and are born with more $luid in the lungs, predisposing the newborn to transient tachypnea (TTC" and respiratory distress. The pre$erable lowAtransverse uterine incision usually results in less postoperative pain, less bleeding, and less incidents o$ ruptured uterus. The classical, vertical incision on the uterus may involve part o$ the $undus, resulting in more 20 postoperative pain, bleeding, and an increased chance o$ uterine rupture. Due to the exploration and cleansing o$ the uterus 1ust a$ter delivery o$ the placenta, the amount o$ lochia may be scant in the recovery room. (owever, pooling in the vagina and uterus while on bedrest may result in blood running down the client/s leg when she $irst ambulates. 2esarean birth clients have the same lochial changes, placental site healing, and aseptic needs as do vaginal birth clients. A laparotomy o$ any )ind, including cesarean birth, predisposes the client to postoperative paralytic ileus. :hen the bowel is manipulated in surgery, it ceases preistalsis, which may persist. Symptoms include+ absent bowel sounds, abdominal distention, tympany on percussion, nausea and vomiting, and o$ course, obstipation (intractible constipation". *arly ambulation is an e$$ective nursing intervention. POSTPARTUM HIGH4RISK DISORDERS Curse must be especially supportive o$ postpartum client with in$ection because it usually implies isolation $rom newborn until organism is identi$ied and treatment begun. Arrange phone calls to nursery and window viewing. #nvolve $amily, spouse, signi$icant others in teaching, and encourage other $amily members to continue neonatal attachment activities. .ost common iatrogenic cause o$ 7T# is urinary catheteri@ation. *ncourage clients to void $re<uently and not ignore the urge. #? antibiotic are usually administered to clients with pyelonephritis. Remember, the ris) o$ postpartum in$ections increases $or clients who experienced problems during pregnancy (e.g., anemia, diabetes" or experienced trauma during labor and delivery. 2lients ta)ing anticoagulants can usually expect to have heavy menstrual periods. #n most cases, a mother who is on antibiotic therapy can continue to breast$eed unless the healthcare provider thin)s the neonate is at ris) $or sepsis by maternal contact. Sul$a drugs are used cautiously in lactating mothers because they can be trans$erred to the in$ant in breast mil). .any times mastitis can be con$used with a bloc)ed mil) sinus, which is treated by nursing closer to the lump and by rotating the baby on the breast. -reast$eeding is not contraindicated $or women with mastitis, unless pus is in the breast mil), or the antibiotic o$ choice is harm$ul to the in$ant. #$ either o$ these occurs, mil) production can still be $ostered by manual expression. During medical emergencies such as bleeding episodes, clients need calm, direct explanations and assurance that all is being done that can be done. #$ possible, allow support person at bedside. Ris)Amanagement principles state that the suitAprone client is one who $eels things are being hidden $rom her or that ade<uate attention is C&T being give to (*R problem. Ris) $actors $or hemorrhage include+ dystocia, prolonged labor, over distended uterus, abruptio placentae, and in$ection. :hat immediate nursing actions should be ta)en when a postpartum hemorrhage is detected= - %er$orm $undal massage - Coti$y the healthcare provider i$ the $undus does not become $irm with massage - 2ount pads to estimate blood loss - Assess and record vital signs - #ncrease #? $luids (additional #? line may be indicated" - Administer oxytocin in$usion as prescribed NEWBORN HIGH4RISK DISORDERS IRitterinessJ is a clinical mani$estation o$ hypoglycemia and hypocalcemia. ;aboratory analysis is indicated to di$$erentiate between two etiologies. To avoid metabolic problems brought on by cold stress, the $irst step and number one priority, in management o$ the newborn is to prevent loss o$ body heat, $ollowed by A-2s. Ceonates produce heat by nonAshivering thermogenesis, by burning brown $at. The neonate is easily stressed by hypothermia and develops acidosis $rom hypoxia. %revent chilling ()eep under radiant warmer or in isolette". #$ cold, the $irst signs exhibited are prolonged acrocyanosis, s)in mottling, tachycardia, and tachypnea. #$ cold stressed, warm slowly over ' to 4 hours since rapid warming may produce apnea. The neonate needs glucose, he0she has little glycogen storage and needs to be $ed. The lower the score on the SilvermanAAnderson index o$ Respiratory Distress, the better the respiratory status o$ the neonate. A score o$ , indicates that a newborn is in severe respiratory distress. This is the exact opposite o$ the method used $or Apgar scoring. :AT2( the newborn (ct> it is di$$icult to oxygenate either an anemic newborn (lac) o$ oxygenAcarrying capacity" or a newborn with polycythemia ((ct 3N!, thich, sluggish circulation". The %&' should be maintained between 5 to Q mm(g. %&' 55 signi$ies hypoxia, %&' 3 Q signi$ies oxygen toxicity problems. Antibiotic dosage is based on the neonate/s weight in )ilograms. %ea) and trough drug levels are drawn to evaluate i$ therapeutic drug levels have been achieved. 2losely monitor the neonate $or adverse e$$ects o$ A;; drugs. Sepsis can be indicated by both a temperature increase and a temperature decrease. Drugs used to treat neonatal in$ections can be ototoxic and nephrotoxic. 2lose monitoring o$ therapeutic levels and observation $or side e$$ects are re<uired. Renal immaturity in the preterm in$ant ma)es the monitoring o$ #? $luid administration and drug therapy crucial. 2losely monitor -7C and creatinine levels when administering the ImycinJ antibiotics to treat in$ections in the neonate. 21 #$ tube passes into trachea, newborn can ma)e C& noise, i.e., no crying. Cewborn may gag, cough, or become cyanotic. To assess $or s)in 1aundice, apply with thumb over bony prominences to blanch s)in. A$ter removing thumb, area will loo) yellow be$ore normal s)in color reappears. The best areas $or assessment are the nose, $orehead, and sternum. #n dar)As)inned in$ants, observe con1unctival sac and oral mucosa. ;ab tests measure total and direct (con1ugated, excretable, nonA$at soluble" bilirubin levels. The dangerous bilirubin is the uncon1ugated, indirect ($atAsoluble", which is measured by subtracting the direct $rom the total bilirubin. .aintenance o$ hydration is crucial $or all in$ants. The preterm in$ant is already at ris) $or $luid and electrolyte imbalances due to increased body sur$ace area $rom extended body positioning and larger body area in related to body weight. %hototherapy treatment $or hyperbilirubinemia (level 3 ,' mg0dl" increases the ris) $or dehydration. PSYCHIATRIC NURSING THERAPEUTIC COMMUNICATION / TREATMENT MODALITIES The purpose o$ therapeutic interaction with clients is to allow them the autonomy to ma)e choices when appropriate. Heep statements value $ree, advice $ree, and reassurance $ree. Remember, R7ST T(* 9A2TSO C& &%#C#&CSO :hat action should the nurse ta)e in a Ipsychiatric situationJ when the client describes a physical problem= Assess, assess, assessO #$ the client with paranoid schi@ophrenia on the psychiatric unit complains o$ chest pain, ta)e his0her blood pressure. #$ the &- client who has delivered a dead $etus complains o$ perineal pain K loo) at the perineal area (she may have a hematoma". Rust because the $ocus o$ the client/s situation is on his0her psychological needs, it does not mean that the nurse can ignore physiological needs. Remember, nurses are IniceJ people, but they are also therapeutic. -asic communication principles can be applied to all clients+ - *stablish trust. - Demonstrate a nonA1udgmental attitude - &$$er sel$> be emphathetic, C&T sympathetic - 7se active listening - Accept and support client/s $eelings - 2lari$y and validate client/s statement - 7se matterAo$A$act approach Remember, a nurse/s nonverbal communication may be more important that his0her verbal communication. A <uestion concerning nurseAclient con$identiality o$ten appears on the C2;*DARC. 9or the nurse to tell a client she0he will not tell anyone about their discussion, puts the nurse in a di$$icult position. Some in$ormation .7ST be shared with other team members $or the client/s sa$ety (e.g., suicide plan" and optimal therapy. Causea is a common complaint a$ter *2T. ?omiting by the unconscious client can lead to aspiration. -ecause postA *2T clients are unconscious, the nurse must observe closely $or the possibility o$ aspiration, i.e., .A#CTA#C A %AT*CT A#R:ABO AN9IETY DISORDERS 2ommon physiological responses to anxiety include increased heart rate and blood pressure> rapid, shallow respirations> dry mouth, tight $eeling in throat> tremors, muscle tension> anorexia> urinary $re<uency> palmar sweating. Anxiety is very contagious and is easily trans$erred $rom client to nurse ACD $rom nurse to client. 9#RST, the nurse must assess his0her own level o$ anxiety and remain calm. A calm nurse assists the client to gain control, decrease anxiety, and increase $eelings o$ anxiety. :hen a client described a phobia or expresses an unreasonable $ear, the nurse should ac)nowledge the $eeling ($ear" and re$rain $rom exposing the client to the identi$ied $ear. A$ter trust is established, a desensiti@ation process may be prescribed. Desensiti@ation is the nursing intervention $or phobia disorders. The nurse should+ - Assist client to recogni@e $actors associated with $eared stimuli that precipitate a phobic response. - Teach and practice with client alternative adaptive coping strategies such as the use o$ thought substitution (replacing a $ear$ul thought with a pleasant thought", and relaxation techni<ues. RoleAplaying is use$ul when the client is in a calm state. - *xpose client progressively to $eared stimuli, o$$ering support with the nurse/s presence. - %rovide positive rein$orcement whenever a decrease in phobic reaction occurs. - C&T*+ #n all li)elihood, the desensiti@ation process will be overseen by a mental health practitioner (C% psych 2CS, or psychologist". The nurse should place an anxious client where there are reduced environmental stimuli K a <uiet area o$ the unit, away $rom the nurse/s station. The best time $or interaction with a client is at the completion o$ the per$ormed ritual. The client/s anxiety is lowest at this time> there$ore, it is an optimal time $or learning. 2ompulsive acts are used in response to anxiety, which may or may not be related to the obsession. #t is the nurse/s responsibility to help alleviate anxiety. #nter$ering will increase anxiety. These acts should be allowed as long as the client/s acts are $ree o$ violence. The nurse should+ - Actively listen to the client/s obsessive themes - Ac)nowledge e$$ects that ritualistic acts have on the client - Demonstrate empathy - Avoid being 1udgmental 9or clients with postraumatic stress disorder, the nurse should+ - Actively listen to client/s stories o$ experiences surrounding the traumatic event - Assess suicide ris) 22 - Assist client to develop ob1ectivity about the event and problem solve regarding possible means o$ controlling anxiety related to the event - *ncourage group therapy with other clients who have experienced the same or related traumatic events SOMATO7ORM DISORDERS -e aware o$ your own $eelings when dealing with this type o$ client. #t is a challenge to be nonA1udgmental. The pain is real to the person experiencing it. These disorders cannot be explained medically+ they result $rom internal con$lict. The nurse should+ - Ac)nowledge the symptom or complaint - Rea$$irm that diagnostic test results reveal no organic pathology - Determine the secondary gains ac<uired by the client DISSOCIATIVE DISORDERS The nurse should be aware that A;; behavior has meaning. Avoid giving clients with dissociative disorders too much in$ormation about past events at one time. The various types o$ amnesia, which accompany dissociative disorders, provide protection $rom pain. Too much, too soon, may cause decompensation. PERSONALITY DISORDERS %ersonality disorders are longAstanding behavioral traits that are maladaptive responses to anxiety and cause di$$iculty in relating and wor)ing with other individuals. C2;*DARC <uestions test personality disorder content by describing management situations. %ersons with a personality disorder are usually com$ortable with their disorder and believe that they are right and the world is wrong. These individuals usually have very little motivation to change. Thin) o$ them as a 2(A;;*C8*. EATING DISORDERS %eople with Anorexia gain pleasure $rom providing others with $ood and watching them eat. These behaviors rein$orce their perception o$ sel$Acontrol. Do not allow these clients to plan or prepare $ood $or unitAbased activities. %eople with -ulimia o$ten use syrup o$ ipecac to induce vomiting which may cause cardiovascular problems such as congestive heart $ailure (2(9". -ecause 2(9 is not usually seen in young people, it is o$ten overloo)ed. Assess $or edema and listen to breath sounds. %hysical assessment and nutritional support are a priority> the physiological implications are great. Cursing interventions should increase sel$Aesteem and develop a positive body image. -ehavior modi$ication is use$ul and e$$ective. 9amily therapy is most e$$ective since issues o$ control are common in these disorders. (Therapy is usually long term". MOOD DISORDERS Depressed clients have di$$iculty hearing and accepting compliments because o$ their lowered sel$Aconcept. 2omment on signs o$ improvement by noting the behavior, e.g., I# noticed you cobed your hair todayJ C&T, IBou loo) nice today.J The most important signs and symptoms o$ depression are a depressed mood with a loss o$ interest or pleasure in li$e. The client has sustained a loss. &ther symptoms include+ - Signi$icant change in appetite o$ten accompanied by a change in weight K either weight loss or gain - #nsomnia or hyperinsomnia (usually sleeping during the day K o$ten because the client is not sleeping at night due to anxiety". - 9atigue or a lac) o$ energy - 9eelings o$ hopelessness, worthlessness, guilt, or overA responsibility - ;oss o$ ability to concentrate or thin) clearly - %reoccupation with death or suicide The nurse )nows depressed clients are improving when they begin to ta)e an interest in their appearance or begin to per$orm sel$Acare activities, which were previously o$ little or no interest. The nurse should suspect an imminent suicide attempt i$ a depressed client becomes Ibetter,J e.g., happy or even elated. -e aware K a happy a$$ect may signi$y that the client $eels relieved that a plan has been made and he0she is ready $or the suicide attempt. :hen dealing with a depressed client, the nurse should assist with personal hygiene tas)s and encourage the client to initiate grooming activities even when he0she does not $eel li)e doing so. This helps promote sel$Aesteem and a sense o$ control. An important intervention $or the depressed client is to sit <uietly with the client. :hen answering C2;*DARC <uestions, remember that you are wor)ing at 7topia 8eneral and there is plenty o$ time and sta$$ to provide ideal nursing care. Do not let realities o$ clinical situations deter you $rom choosing the best nursing intervention. The best intervention is to sit <uietly with the client, o$$ering support with your presence. There are always drug <uestions on the C2;*DARC. (ere are some tips+ Hnow common side e$$ects $or drug groups. 9or example+ - AntiAanxiety drugs S sedation, drowsiness - Antidepressant drugs S anticholinergic e$$ects, postural hypotension - .A& inhibitors S hypertensive crisis Hnow speci$ic problems or concerns $or drug therapy. 9or example+ - ;ithium re<uires renal $unction assessment and monitoring - %henothia@ines cause extrapyramidal e$$ects (*%S"> tardive dys)inesia can be permanent i$ client is not assessed regularly $or signs o$ tardive dys)inesiaO Hnow speci$ic client teaching $or drug therapy. 9or example+ - %henothia@ines S photosensitivity, need to wear protective clothing, sunglasses - .A& inhibitors S dietary restrictions to prevent hypertensive crisis 23 .onitor serum lithium levels care$ully. The therapeutic range is between .5 and ,.5 m*<0;. the therapeutic and toxic levels are very close in reading. Signs o$ toxicity are evident when lithium levels are more than ,.5 m*<0;. -lood levels should be drawn ,' hours a$ter ;AST dose. .anic clients can be very caustic toward authority $igures. -e prepared $or personal Iput downs.J Avoid arguing or becoming de$ensive. :hat activities are appropriate $or a manic client= S Concompetitive physical activities, which re<uire the use o$ large muscle groups. :here should a manic client be placed on the unit= S .a)e every attempt to reduce stimuli in the environment. %lace the client in a <uiet part o$ the unit. :hat interventions should the nurse use i$ a client becomes abusive= - Redirect negative behavior or verbal abuse in a calm, $irm, nonA1udgmental, nonAde$ensive manner - Suggest a wal) or physical activity - Set limits on intrusive behavior. 9or example, I:hen you interrupt, # cannot explain the procedure to the others> please wait your turn.J - #$ necessary, seclude or administer medication i$ client becomes totally out o$ control. Always remember to use compassion because nurses are IniceJ people. Two atypical antipsychotic drugs are also indicated $or mania (risperidone and olan@apine". THOUGHT DISORDERS: SCHI:OPHRENIA There are $ive types o$ schi@ophrenia speci$ied under the DS.A#?ATR. The DS.A#?ATR is a diagnostic manual prepared by the American %sychiatric Association that provides diagnostic criteria $or all psychiatric disorders. &bserve $or increased motor activity and0or erratic response to sta$$ and other clients. The client may be experiencing an increase in command hallucinations. :hen this occurs, there is an increased potential $or aggressive behavior. T(#CH %RCO :hen evaluating client behaviors, consider the medications the client is receiving. *xhibited behaviors may be mani$estations o$ schi@ophrenia or a drug reaction. 7se -leuler/s $our As to help remember the important characteristics o$ schi@ophrenia+ - Autism (preoccupied with sel$" - A$$ect ($lat" - Association (loose" - Ambivalence (di$$iculty ma)ing decisions" Do not argue with a client about their delusions. ;ogic does C&T wor), it only increases the client/s anxiety. -e matterAo$A $act and divert delusional thought to reality. Trust is the basis $or all interactions with these clients. -e supportive and nonA 1udgmental. Stress increases anxiety and the need $or delusions and hallucinations. Do not agree you hear voices (you should be the client/s contact to reality", but ac)nowledge your observation o$ the client, $or example, IBou loo) li)e you/re listening to something.J Hnow the side e$$ects o$ drugs commonly used to treat schi@ophrenia since client behavioral changes may be due to drug reactions instead o$ schi@ophrenia. SUBSTANCE ABUSE Hnow what de$ense mechanisms are used by chemically dependent clients. Denial and rationali@ation are the two most common coping styles used K their use must be con$ronted so accountability $or the client/s own behavior can be developed. :hat basic needs have priority when wor)ing with chemically dependent clients= Cutrition is a priority. Alcohol and drug inta)e has superseded the inta)e o$ $ood $or these clients. :hat behaviors are expected during withdrawal= #n the alcoholic, delirium tremens (DT" occurs ,' to F6 hours a$ter the last inta)e o$ alcohol. Hnow the symptoms (tachycardia, tachypnea, diaphoresis, mar)ed tremors, hallucinations, paranoia". #n drug abuse, withdrawal symptoms are speci$ic to the type o$ drug. :hat medications can the nurse expect to administer to chemically dependent clients= #n treating alcohol withdrawal, ;ibrium or Ativan are commonly used. Antabuse is o$ten used as s deterrent to drin)ing alcohol. 2lient teaching should include the e$$ects o$ consuming any alcohol while on Antabuse. *ncourage client to read all labels o$ overAtheAcounter medications and $ood products, which may contain small amounts o$ alcohol. :hat type o$ therapy is used with chemically dependent clients= 8roup therapy is e$$ective as well as support groups such as Alcoholics Anonymous, Carcotics Anonymous, etc. (arm reduction is a community health strategy designed to reduce the harm o$ substance abuse to $amilies, individuals, community, and society. - .ore compassionate drug treatment options including abstinence and drug substitution models. - (#? related interventions such as needle exchanges - Directed drug use management should the client wish to continue use - 2hanges in laws concerning possession o$ paraphernalia ABUSE Select only one nurse to care $or an abused child. Abused children have di$$iculty establishing trust. The child will be less anxious with one consistent caregiver. :omen who are abused may rationali@e the spouse/s behavior and unnecessarily accept the blame $or his actions. The woman may or may not choose to press charges. -e sure to give her the number o$ a shelter $or Ihelp lineJ $or $uture occurrences, as well as develop a sa$ety plan. #t is di$$icult $or an elderly person to admit abuse $or $ear being placed in a nursing home or being abandoned. 24 There$ore, it is imperative to establish a trusting relationship with the elderly client. Rape victims are at high ris) $or %ost Traumatic Stress Disorder (%TSD". #mmediate intervention to diminish distress is vital. The nurse should also assess $or and intervene $or se<uellae such as unwanted pregnancy, sexually transmitted diseases, and (#? ris). Euestions on the C2;*DARC regarding physical0sexual abuse usually $ocus on three aspects+ - %hysical mani$estations o$ abuse - 2lient sa$ety - ;egal responsibilities o$ the nurse K #n children, the nurse is legally responsible to report all suspected cases o$ abuse. #n intimate partner abuse, it is the adult/s decision> the nurse should be supportive o$ their decision. Remember to document ob1ective $actual assessment data and the client/s exact words in cases o$ sexual abuse0rape. ORGANIC MENTAL DISORDERS 2on$usion in the elderly is o$ten IacceptedJ as part o$ growing old. This con$usion may be due to dehydration with resulting electrolyte imbalance. Thin) Isudden changeJ when obtaining a history. Such changes are usually due to a speci$ic stressor, and treatment $or the causative stressor will usually result in correcting the con$usion. 2on$abulation is not lying. #t is used by the client to decrease anxiety and protect the ego. Cursing interventions $or the con$used elderly should $ocus on+ - .aintaining the client/s health and sa$ety - *ncouraging sel$ care - Rein$orcing reality orientation (e.g., IToday is .onday,J and call the client by name". - %roviding a consistent, sa$e environment K engage client in simple tas)s, activities to build sel$Aesteem %roviding consistent caregiver is a priority in planning nursing care $or the con$used older client. 2hange increases anxiety and con$usion. .ay also use atypical antipsychotics such as resperidine, <uetiapine, olan@apine, 2lo@aril is not a $rontAline agent due to sideAe$$ects. .ay also give mood stabili@ers and antianxiety medications as indicated. The basic di$$erence between delirium and dementia is that delirium is acute, and reversible, whereas dementia is gradual and permanent. CHILDHOOD AND ADOLESCENT DISORDERS 2hildren also experience depression, which o$ten presents as headaches, stomachaches, and other somatic complaints. -e sure to assess suicidal ris)s, especially in the adolescent. The client/s lac) o$ remorse or guilt about their antisocial behavior represents a mal$unction o$ the superego or conscience. The id $unctions on the basic instinct level and strives to meet immediate needs. The ego is in touch with external reality and is the part o$ the personality that ma)es decisions. #mportant points to remember when answering C2;*DARC <uestions+ - These children may be involved in sel$A$ul$illing prophecy (e.g., I.om says that he0she is a troubleAma)er, there$ore, he0she must live up to .om/s expectationsJ". - 2on$ront the client with his0her behavior, e.g., lying. This gives the client a sense o$ security. - %rovide consistent interventions K helps to prevent manipulation. #nconsistency does not help the client develop sel$Acontrol. GERONTOLOGICAL NURSING 2hanges in the heart and lungs result in less e$$icient utili@ation o$ &', which reduces an individual/s capacity to maintain physical activity $or long periods o$ time. %hysical training $or older persons can signi$icantly reduce blood pressure and increase aerobic capacity. C2;*DARC <uestions as) about teaching and designing rehab programs $or the elderly K they should contain something about exercise and nutrition. &lder persons o$ten complain that they cannot get to sleep at night and do not sleep soundly even a$ter they $all asleep. This is because they have shorter stages o$ sleep, particularly shorter cycles $rom stages , to 4 and R*. sleep (stage 4 is deep sleep". They are easily awa)ened by environmental stimuli. They o$ten compensate by napping during the day, which leads to $urther disruptions o$ night sleep. A common response is use o$ prescription sleeping pills which can create still $urther problems o$ disorientation, etc. -oth systolic and diastolic blood pressure tend to increase with normal aging, but the elevation o$ the systolic is greater. R*.*.-*R the physiologic o$ blood pressure, which is expressed as a ratio o$ systolic to diastolic pressure. Systolic re$ers to the level o$ blood pressure during the contraction phase whereas diastolic re$ers to the stage when the chambers o$ the heart are $illing with blood. Dysrhythmias in the elderly are particularly serious since older persons cannot tolerate decreased cardiac output, which can result in syncope, $alls, and transient ischemic attac)s (T#As". %ulse may be rapid, slow, or irregular. Angina symptoms may be absent in the elderly or they may be con$used with 8# symptoms. :ith aging, the muscles that operate the lings lose elasticity so that respiratory e$$iciency is reduced. ?ital capacity (the amount o$ air brought into the lungs at one time" decreases. -reathing may become more di$$icult a$ter strenuous exercise or a$ter climbing up several $lights o$ stairs. The rate o$ decline has been $ound to be slower in more active persons. The nurse should encourage older persons to remain physically active $or as long as possible. Declining muscle strength may impair cough e$$iciency. This $act ma)es older persons more susceptible to chronic bronchitis, emphysema, and pneumonia. 2&%D is the ma1or cause o$ respiratory disability in the elderly. 25 Aging changes that contribute to chronic constipation+ - The number o$ en@ymes in the small intestine is reduced and simple sugars are absorbed more slowly, resulting in decreased e$$iciency o$ the digestive process. - The smooth muscle content and muscle tone o$ the wall o$ the colon decrease. Anatomical changes in the large intestine result in decreased intestinal motility. - %sychological $actors, as well as abuse o$ overAtheAcounter laxatives - Decreases in $luid inta)e and mobility contribute to constipation Tooth loss is C&T a normal aging process. 8ood dental hygiene, good nutrition, and dental care can prevent tooth loss. &lder persons appear to eat small <uantities o$ $ood at mealtimes. This is because the digestive system o$ older persons $eatures a decrease in contraction time o$ the muscles and more time is needed $or the cardiac sphincter to open. There$ore, it ta)es more time $or the $ood to be transmitted to the stomach. Thus, the sensation o$ $ullness may occur be$ore the entire meal is consumed. &lder persons have a higher ris) o$ developing renal $ailure because normal ageArelated changes result in compromised renal $unctioning. The nurse should pay care$ul attention to urinary output in older clients because it is the $irst sign o$ loss o$ renal integrity. Hegel exercises consist o$ tightening and relaxing the vaginal and urinary meatus muscles. These exercises have been very success$ul in reducing the incidence o$ incontinence. They must be done consistently, and they can be done unobtrusively at home. The elderly with incontinence may see) isolation, thereby predisposing themselves to loneliness. ,5 to F! o$ communityAbased elderly and almost 5! o$ elderly living in nursing homes su$$er $rom di$$iculties with bladder control. &lder persons may be more sensitive to alcohol and ca$$eine since these substances inhibit the production o$ antidiuretic hormone (AD(". An assessment o$ sensitivity to bladder problems is essential when planning nursing care. .*D#2AT#&C A;*RT+ - As one ages, the total number o$ $unctioning glomeruli decreases until $unction has been reduced by nearly 5!. This decrease in the $iltration e$$iciency o$ the )idneys has grave implications $or persons who are ta)ing medication. &$ particular importance are penicillin, tetracycline, and digoxin, which are primarily cleared $rom the blood stream by the )idneys. These drugs remain active longer in an older person/s system. There$ore, they may be more potent, indicating a need to ad1ust the dosage $re<uency o$ administration. Al@heimer/s disease is the most common irreversible dementia o$ old age. #t is characteri@ed by de$icits in attention, learning, memory, and language s)ills. Discuss the problems $amily members have in dealing with Al@heimer/s clients in relation to the $ollowing disease mani$estations+ - Depression - Cight wandering - Aggressive or passiveness - 9ailure to recogni@e $amily members Stro)es $rom cerebral thrombosis are more common in older persons than are stro)es $rom cerebral hemorrhage. 2lots tend to develop when patient is awa)e or 1ust arousing. Cormal loss o$ brain cells is compounded by alcohol, smo)ing, and breathing polluted air. #n relation to such losses, the nurse should teach to shop at uncrowded times in stores that are $amiliar to them, slow down well in advance o$ tra$$ic signals, stay in the slower lane o$ the $reeway, avoid $reeways during rush hours, and leave $or appointments well ahead o$ time. The most common endocrine disorders in the older adult are thyroid dys$unctions and diabetes. #mpaired mobility, impaired s)in integrity, decreased peripheral circulation, and a lac) o$ physical activity place the elderly at ris) $or developing decubitus ulders. :ays to help prevent0decrease the occurrence o$ $alls+ - Ade<uate lighting - %ain the edges o$ stairs a bright color - %lace a bell on the elderly person/s cat (since cats move <uic)ly and get under$oot" - :ear proper $ootwear that supports the $oot and contributes to balance (made o$ nonAslippery materials". %eripheral circulation decreases as one ages. Regular assessment o$ the $eet is very important because it increases the opportunity to discover and treat s)in care problems early. These problems could become more serious because o$ decreased circulation. &lder persons have a dry, wrin)led s)in because they lose subcutaneous $at and the second layer o$ s)in, the dermis, becomes less elastic. Diminished eyesight results in+ - A loss o$ independence (AD; and driving" - A lac) o$ stimulation - The inability to read - A $ear o$ blindness ;ower the tone o$ your voice when tal)ing to an older person who is hearingAimpaired. (ighApitched tones (i.e., women/s voices" are the $irst hearing to go, there$ore, lowering the pitch o$ your voice increases the li)elihood that an older person with a hearing loss will be able to hear you spea). %resbycusis (ageArelated hearing loss" can result in decreased sociali@ation, avoidance o$ $riends and $amily, decreased sensory stimulation, and ha@ardous conditions when driving. 7se $re<uent touch to decrease the sense o$ isolation and to compensate $or visual and sensory loss. &lder persons undergo a great many changes, which are usually associated with ;&SS (loss o$ spouse, $riends, 26 career, home, health, etc.". there$ore, older persons are extremely vulnerable to emotional and mental stress. #CT*8R#TB ?S. D*S%A#R is *ri)son/s $inal stage o$ growth and development. Reminiscing is a means o$ setting one/s li$e in order (accepting li$e and sel$", which is the tas) o$ this stage o$ *ri)son/s development theory. The goal o$ this stage is to $eel a sense o$ meaning in one/s li$e, rather than to $eel despair or bitterness that li$e was wasted. The ma1or tas) o$ old age is to rede$ine sel$ in relation to a changed role. Those persons who had been in charge o$ situations most o$ their lives may now $und themselves in dependent positions. The role ad1ustment is a ma1or tas) o$ old age. Thin) about the $ollowing situations and discuss the nursing care $or each. - A nursing supervisor who has had a stro)e and is sent to a long term $acility $or rehabilitation. - An oil company executive retires a$ter 4' years with the company to travel in his recreational vehicle wit his wi$e and dog. - Shortly a$ter their 5F rd wedding anniversary, a woman who has never wor)ed outside the home loses her husband to brain cancer. There are many conditions that can imitate dementia in the older adult. A )ey role $or the nurse is to complete assessment to rule out other possible causes. 27
HESI A2 Admission Assessment Study Guide: COMPLETE Health Information Systems A2® Study Guide and Practice Test Questions prepared by a dedicated team of test experts!